hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|AR,"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.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Dallas County Medical Center,2/28/2025,2.0.0,Dallas County Medical Center,"201 N Clifton ST, Fordyce, AR 71742",270029542,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|AMBETTER|MEDICARE|negotiated_dollar,standard_charge|AMBETTER|MEDICARE|negotiated_percentage,standard_charge|AMBETTER|MEDICARE|negotiated_algorithm,estimated_amount|AMBETTER|MEDICARE,standard_charge|AMBETTER|MEDICARE|methodology,additional_payer_notes|AMBETTER|MEDICARE,standard_charge|AR_TOTALCARE_COMMERCIAL_EXCHANGE|MEDICARE|negotiated_dollar,standard_charge|AR_TOTALCARE_COMMERCIAL_EXCHANGE|MEDICARE|negotiated_percentage,standard_charge|AR_TOTALCARE_COMMERCIAL_EXCHANGE|MEDICARE|negotiated_algorithm,estimated_amount|AR_TOTALCARE_COMMERCIAL_EXCHANGE|MEDICARE,standard_charge|AR_TOTALCARE_COMMERCIAL_EXCHANGE|MEDICARE|methodology,additional_payer_notes|AR_TOTALCARE_COMMERCIAL_EXCHANGE|MEDICARE,standard_charge|AR_TOTALCARE_MEDICARE_ADV|MEDICARE|negotiated_dollar,standard_charge|AR_TOTALCARE_MEDICARE_ADV|MEDICARE|negotiated_percentage,standard_charge|AR_TOTALCARE_MEDICARE_ADV|MEDICARE|negotiated_algorithm,estimated_amount|AR_TOTALCARE_MEDICARE_ADV|MEDICARE,standard_charge|AR_TOTALCARE_MEDICARE_ADV|MEDICARE|methodology,additional_payer_notes|AR_TOTALCARE_MEDICARE_ADV|MEDICARE,standard_charge|BCBS_AR_FIRST_SOURCE0_PPO|COMMERCIAL|negotiated_dollar,standard_charge|BCBS_AR_FIRST_SOURCE0_PPO|COMMERCIAL|negotiated_percentage,standard_charge|BCBS_AR_FIRST_SOURCE0_PPO|COMMERCIAL|negotiated_algorithm,estimated_amount|BCBS_AR_FIRST_SOURCE0_PPO|COMMERCIAL,standard_charge|BCBS_AR_FIRST_SOURCE0_PPO|COMMERCIAL|methodology,additional_payer_notes|BCBS_AR_FIRST_SOURCE0_PPO|COMMERCIAL,standard_charge|BCBS_HEALTH_ADVANTAGE_HMO|COMMERCIAL|negotiated_dollar,standard_charge|BCBS_HEALTH_ADVANTAGE_HMO|COMMERCIAL|negotiated_percentage,standard_charge|BCBS_HEALTH_ADVANTAGE_HMO|COMMERCIAL|negotiated_algorithm,estimated_amount|BCBS_HEALTH_ADVANTAGE_HMO|COMMERCIAL,standard_charge|BCBS_HEALTH_ADVANTAGE_HMO|COMMERCIAL|methodology,additional_payer_notes|BCBS_HEALTH_ADVANTAGE_HMO|COMMERCIAL,standard_charge|BCBS_HEALTH_ADVANTAGE_MEDICARE_HMO|MEDICARE|negotiated_dollar,standard_charge|BCBS_HEALTH_ADVANTAGE_MEDICARE_HMO|MEDICARE|negotiated_percentage,standard_charge|BCBS_HEALTH_ADVANTAGE_MEDICARE_HMO|MEDICARE|negotiated_algorithm,estimated_amount|BCBS_HEALTH_ADVANTAGE_MEDICARE_HMO|MEDICARE,standard_charge|BCBS_HEALTH_ADVANTAGE_MEDICARE_HMO|MEDICARE|methodology,additional_payer_notes|BCBS_HEALTH_ADVANTAGE_MEDICARE_HMO|MEDICARE,standard_charge|BCBS_TRUE_BLUE_PPO|COMMERCIAL|negotiated_dollar,standard_charge|BCBS_TRUE_BLUE_PPO|COMMERCIAL|negotiated_percentage,standard_charge|BCBS_TRUE_BLUE_PPO|COMMERCIAL|negotiated_algorithm,estimated_amount|BCBS_TRUE_BLUE_PPO|COMMERCIAL,standard_charge|BCBS_TRUE_BLUE_PPO|COMMERCIAL|methodology,additional_payer_notes|BCBS_TRUE_BLUE_PPO|COMMERCIAL,standard_charge|CARESOURCE_MARKETPLACE|MEDICARE|negotiated_dollar,standard_charge|CARESOURCE_MARKETPLACE|MEDICARE|negotiated_percentage,standard_charge|CARESOURCE_MARKETPLACE|MEDICARE|negotiated_algorithm,estimated_amount|CARESOURCE_MARKETPLACE|MEDICARE,standard_charge|CARESOURCE_MARKETPLACE|MEDICARE|methodology,additional_payer_notes|CARESOURCE_MARKETPLACE|MEDICARE,standard_charge|CARESOURCE_MEDICAID|MEDICAID|negotiated_dollar,standard_charge|CARESOURCE_MEDICAID|MEDICAID|negotiated_percentage,standard_charge|CARESOURCE_MEDICAID|MEDICAID|negotiated_algorithm,estimated_amount|CARESOURCE_MEDICAID|MEDICAID,standard_charge|CARESOURCE_MEDICAID|MEDICAID|methodology,additional_payer_notes|CARESOURCE_MEDICAID|MEDICAID,standard_charge|CARESOURCE_MEDICARE_ADV|MEDICARE|negotiated_dollar,standard_charge|CARESOURCE_MEDICARE_ADV|MEDICARE|negotiated_percentage,standard_charge|CARESOURCE_MEDICARE_ADV|MEDICARE|negotiated_algorithm,estimated_amount|CARESOURCE_MEDICARE_ADV|MEDICARE,standard_charge|CARESOURCE_MEDICARE_ADV|MEDICARE|methodology,additional_payer_notes|CARESOURCE_MEDICARE_ADV|MEDICARE,standard_charge|MEDICAID|MEDICAID|negotiated_dollar,standard_charge|MEDICAID|MEDICAID|negotiated_percentage,standard_charge|MEDICAID|MEDICAID|negotiated_algorithm,estimated_amount|MEDICAID|MEDICAID,standard_charge|MEDICAID|MEDICAID|methodology,additional_payer_notes|MEDICAID|MEDICAID,standard_charge|MEDICARE|MEDICARE|negotiated_dollar,standard_charge|MEDICARE|MEDICARE|negotiated_percentage,standard_charge|MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|MEDICARE|MEDICARE,standard_charge|MEDICARE|MEDICARE|methodology,additional_payer_notes|MEDICARE|MEDICARE,standard_charge|UHC_COMMERCIAL|COMMERCIAL|negotiated_dollar,standard_charge|UHC_COMMERCIAL|COMMERCIAL|negotiated_percentage,standard_charge|UHC_COMMERCIAL|COMMERCIAL|negotiated_algorithm,estimated_amount|UHC_COMMERCIAL|COMMERCIAL,standard_charge|UHC_COMMERCIAL|COMMERCIAL|methodology,additional_payer_notes|UHC_COMMERCIAL|COMMERCIAL,standard_charge|UHC_MEDICARE|MEDICARE|negotiated_dollar,standard_charge|UHC_MEDICARE|MEDICARE|negotiated_percentage,standard_charge|UHC_MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|UHC_MEDICARE|MEDICARE,standard_charge|UHC_MEDICARE|MEDICARE|methodology,additional_payer_notes|UHC_MEDICARE|MEDICARE,standard_charge|VACCN|MEDICARE|negotiated_dollar,standard_charge|VACCN|MEDICARE|negotiated_percentage,standard_charge|VACCN|MEDICARE|negotiated_algorithm,estimated_amount|VACCN|MEDICARE,standard_charge|VACCN|MEDICARE|methodology,additional_payer_notes|VACCN|MEDICARE,standard_charge|min,standard_charge|max,additional_generic_notes
SURG SETUP & CANCEL,1001006,CDM,360,RC,,,Outpatient,,,566.00,566.00,,332.53,58.75,,266.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,332.53,58.75,,266.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,274,48.41,,219.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,509.4,90,,407.52,Percent of Total Billed Charges,90% of Total Billed Charges,509.4,90,,407.52,Percent of Total Billed Charges,90% of Total Billed Charges,266.02,47,,212.816,Percent of Total Billed Charges,47% of Total Billed Charges,509.4,90,,407.52,Percent of Total Billed Charges,90% of Total Billed Charges,332.53,58.75,,266.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,266.02,47,,212.816,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,266.02,47,,212.816,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,266.02,47,,212.816,Percent of Total Billed Charges,47% of Total Billed Charges,266.02,47,,212.816,Percent of Total Billed Charges,47% of Total Billed Charges,266.02,509.4,
EQUIP. CHARGE O2 MON,1002021,CDM,360,RC,,,Outpatient,,,121.00,121.00,,71.09,58.75,,56.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,71.09,58.75,,56.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.58,48.41,,46.864,Percent of Total Billed Charges,48.41% of Total Billed Charges,108.9,90,,87.12,Percent of Total Billed Charges,90% of Total Billed Charges,108.9,90,,87.12,Percent of Total Billed Charges,90% of Total Billed Charges,56.87,47,,45.496,Percent of Total Billed Charges,47% of Total Billed Charges,108.9,90,,87.12,Percent of Total Billed Charges,90% of Total Billed Charges,71.09,58.75,,56.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,56.87,47,,45.496,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,56.87,47,,45.496,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,56.87,47,,45.496,Percent of Total Billed Charges,47% of Total Billed Charges,56.87,47,,45.496,Percent of Total Billed Charges,47% of Total Billed Charges,56.87,108.9,
THERMAL MONITOR,1002022,CDM,360,RC,,,Outpatient,,,47.00,47.00,,27.61,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.61,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.75,48.41,,18.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,27.61,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,42.3,
RECOVERY RM 1ST2HRS,1003009,CDM,710,RC,,,Outpatient,,,173.80,173.80,,102.11,58.75,,81.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,102.11,58.75,,81.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.14,48.41,,67.312,Percent of Total Billed Charges,48.41% of Total Billed Charges,156.42,90,,125.136,Percent of Total Billed Charges,90% of Total Billed Charges,156.42,90,,125.136,Percent of Total Billed Charges,90% of Total Billed Charges,81.69,47,,65.352,Percent of Total Billed Charges,47% of Total Billed Charges,156.42,90,,125.136,Percent of Total Billed Charges,90% of Total Billed Charges,102.11,58.75,,81.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,81.69,47,,65.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,81.69,47,,65.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,81.69,47,,65.352,Percent of Total Billed Charges,47% of Total Billed Charges,81.69,47,,65.352,Percent of Total Billed Charges,47% of Total Billed Charges,81.69,156.42,
LEVEL I,1500002,CDM,450,RC,99281,HCPCS,Outpatient,,,345.00,345.00,,202.69,58.75,,162.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,202.69,58.75,,162.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,167.01,48.41,,133.608,Percent of Total Billed Charges,48.41% of Total Billed Charges,310.5,90,,248.4,Percent of Total Billed Charges,90% of Total Billed Charges,310.5,90,,248.4,Percent of Total Billed Charges,90% of Total Billed Charges,162.15,47,,129.72,Percent of Total Billed Charges,47% of Total Billed Charges,310.5,90,,248.4,Percent of Total Billed Charges,90% of Total Billed Charges,202.69,58.75,,162.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,162.15,47,,129.72,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,162.15,47,,129.72,Percent of Total Billed Charges,47% of Total Billed Charges,125,100,,,Case Rate,Pays based on per visit rate,11.79,115,,231.616,Fee Schedule,115% of CMS OPPS Rate,11.79,115,,231.616,Fee Schedule,115% of CMS OPPS Rate,11.79,310.5,
LEVEL IV,1500003,CDM,450,RC,99284,HCPCS,Outpatient,,,1035.00,1035.00,,608.06,58.75,,486.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,608.06,58.75,,486.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,501.04,48.41,,400.832,Percent of Total Billed Charges,48.41% of Total Billed Charges,931.5,90,,745.2,Percent of Total Billed Charges,90% of Total Billed Charges,931.5,90,,745.2,Percent of Total Billed Charges,90% of Total Billed Charges,486.45,47,,389.16,Percent of Total Billed Charges,47% of Total Billed Charges,931.5,90,,745.2,Percent of Total Billed Charges,90% of Total Billed Charges,608.06,58.75,,486.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,486.45,47,,389.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,486.45,47,,389.16,Percent of Total Billed Charges,47% of Total Billed Charges,1698,100,,,Case Rate,Pays based on per visit rate,125.74,115,,89.336,Fee Schedule,115% of CMS OPPS Rate,125.74,115,,89.336,Fee Schedule,115% of CMS OPPS Rate,125.74,1698,
LEVEL V,1500005,CDM,450,RC,99285,HCPCS,Outpatient,,,1294.00,1294.00,,760.23,58.75,,608.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,760.23,58.75,,608.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,626.43,48.41,,501.144,Percent of Total Billed Charges,48.41% of Total Billed Charges,1164.6,90,,931.68,Percent of Total Billed Charges,90% of Total Billed Charges,1164.6,90,,931.68,Percent of Total Billed Charges,90% of Total Billed Charges,608.18,47,,486.544,Percent of Total Billed Charges,47% of Total Billed Charges,1164.6,90,,931.68,Percent of Total Billed Charges,90% of Total Billed Charges,760.23,58.75,,608.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,608.18,47,,486.544,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,608.18,47,,486.544,Percent of Total Billed Charges,47% of Total Billed Charges,1800,100,,,Case Rate,Pays based on per visit rate,182.34,115,,34.216,Fee Schedule,115% of CMS OPPS Rate,182.34,115,,34.216,Fee Schedule,115% of CMS OPPS Rate,182.34,1800,
LEVEL II,1500013,CDM,450,RC,99282,HCPCS,Outpatient,,,475.00,475.00,,279.06,58.75,,223.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,279.06,58.75,,223.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,229.95,48.41,,183.96,Percent of Total Billed Charges,48.41% of Total Billed Charges,427.5,90,,342,Percent of Total Billed Charges,90% of Total Billed Charges,427.5,90,,342,Percent of Total Billed Charges,90% of Total Billed Charges,223.25,47,,178.6,Percent of Total Billed Charges,47% of Total Billed Charges,427.5,90,,342,Percent of Total Billed Charges,90% of Total Billed Charges,279.06,58.75,,223.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,223.25,47,,178.6,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,223.25,47,,178.6,Percent of Total Billed Charges,47% of Total Billed Charges,283,100,,,Case Rate,Pays based on per visit rate,43.55,115,,14.024,Fee Schedule,115% of CMS OPPS Rate,43.55,115,,14.024,Fee Schedule,115% of CMS OPPS Rate,43.55,427.5,
LEVEL III,1500015,CDM,450,RC,99283,HCPCS,Outpatient,,,716.00,716.00,,420.65,58.75,,336.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,420.65,58.75,,336.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,346.62,48.41,,277.296,Percent of Total Billed Charges,48.41% of Total Billed Charges,644.4,90,,515.52,Percent of Total Billed Charges,90% of Total Billed Charges,644.4,90,,515.52,Percent of Total Billed Charges,90% of Total Billed Charges,336.52,47,,269.216,Percent of Total Billed Charges,47% of Total Billed Charges,644.4,90,,515.52,Percent of Total Billed Charges,90% of Total Billed Charges,420.65,58.75,,336.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,336.52,47,,269.216,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,336.52,47,,269.216,Percent of Total Billed Charges,47% of Total Billed Charges,739,100,,,Case Rate,Pays based on per visit rate,73.8,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,73.8,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,73.8,739,
SUBCLAVIAN TRAY,1500017,CDM,270,RC,,,Outpatient,,,616.00,616.00,,361.9,58.75,,289.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,361.9,58.75,,289.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,298.21,48.41,,238.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,554.4,90,,443.52,Percent of Total Billed Charges,90% of Total Billed Charges,554.4,90,,443.52,Percent of Total Billed Charges,90% of Total Billed Charges,289.52,47,,231.616,Percent of Total Billed Charges,47% of Total Billed Charges,554.4,90,,443.52,Percent of Total Billed Charges,90% of Total Billed Charges,361.9,58.75,,289.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,289.52,47,,231.616,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,289.52,47,,231.616,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,289.52,47,,4.552,Percent of Total Billed Charges,47% of Total Billed Charges,289.52,47,,4.552,Percent of Total Billed Charges,47% of Total Billed Charges,289.52,554.4,
VIDEO EQUIP PERUSE,1500019,CDM,360,RC,,,Outpatient,,,237.60,237.60,,139.59,58.75,,111.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,139.59,58.75,,111.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,115.02,48.41,,92.016,Percent of Total Billed Charges,48.41% of Total Billed Charges,213.84,90,,171.072,Percent of Total Billed Charges,90% of Total Billed Charges,213.84,90,,171.072,Percent of Total Billed Charges,90% of Total Billed Charges,111.67,47,,89.336,Percent of Total Billed Charges,47% of Total Billed Charges,213.84,90,,171.072,Percent of Total Billed Charges,90% of Total Billed Charges,139.59,58.75,,111.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,111.67,47,,89.336,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,111.67,47,,89.336,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,111.67,47,,265.832,Percent of Total Billed Charges,47% of Total Billed Charges,111.67,47,,265.832,Percent of Total Billed Charges,47% of Total Billed Charges,111.67,213.84,
OBSERV RM 1ST HOUR,1500025,CDM,762,RC,G0378,HCPCS,Outpatient,,,91.00,91.00,,53.46,58.75,,42.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,53.46,58.75,,42.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.05,48.41,,35.24,Percent of Total Billed Charges,48.41% of Total Billed Charges,81.9,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,81.9,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,42.77,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,81.9,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,53.46,58.75,,42.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,42.77,47,,34.216,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,42.77,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,1648,100,,,Case Rate,Pays based on per visit rate,42.77,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,42.77,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,42.77,1648,
OBSERV RM EA ADDL HR,1500027,CDM,762,RC,G0378,HCPCS,Outpatient,,,37.30,37.30,,21.91,58.75,,17.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.91,58.75,,17.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.06,48.41,,14.448,Percent of Total Billed Charges,48.41% of Total Billed Charges,33.57,90,,26.856,Percent of Total Billed Charges,90% of Total Billed Charges,33.57,90,,26.856,Percent of Total Billed Charges,90% of Total Billed Charges,17.53,47,,14.024,Percent of Total Billed Charges,47% of Total Billed Charges,33.57,90,,26.856,Percent of Total Billed Charges,90% of Total Billed Charges,21.91,58.75,,17.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.53,47,,14.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.53,47,,14.024,Percent of Total Billed Charges,47% of Total Billed Charges,1648,100,,,Case Rate,Pays based on per visit rate,17.53,47,,31.024,Percent of Total Billed Charges,47% of Total Billed Charges,17.53,47,,31.024,Percent of Total Billed Charges,47% of Total Billed Charges,17.53,1648,
OBSV RM ADDL 1/4 HR,1500028,CDM,762,RC,G0378,HCPCS,Outpatient,,,5.50,5.50,,3.23,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,1648,100,,,Case Rate,Pays based on per visit rate,2.59,47,,56.776,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,56.776,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,1648,
SURG RM PER MINUTE,1500030,CDM,360,RC,,,Outpatient,,,12.10,12.10,,7.11,58.75,,5.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.11,58.75,,5.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.86,48.41,,4.688,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.89,90,,8.712,Percent of Total Billed Charges,90% of Total Billed Charges,10.89,90,,8.712,Percent of Total Billed Charges,90% of Total Billed Charges,5.69,47,,4.552,Percent of Total Billed Charges,47% of Total Billed Charges,10.89,90,,8.712,Percent of Total Billed Charges,90% of Total Billed Charges,7.11,58.75,,5.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.69,47,,4.552,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.69,47,,4.552,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.69,47,,39.48,Percent of Total Billed Charges,47% of Total Billed Charges,5.69,47,,39.48,Percent of Total Billed Charges,47% of Total Billed Charges,5.69,10.89,
PCP ENROLLMENT FEE,1500031,CDM,960,RC,,,Outpatient,,,5.00,5.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
ASSESSMENT,1500032,CDM,450,RC,99282,HCPCS,Outpatient,,,475.00,475.00,,279.06,58.75,,187.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,279.06,58.75,,187.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,229.95,48.41,,154.528,Percent of Total Billed Charges,48.41% of Total Billed Charges,427.5,90,,913.68,Percent of Total Billed Charges,90% of Total Billed Charges,427.5,90,,913.68,Percent of Total Billed Charges,90% of Total Billed Charges,223.25,47,,150.024,Percent of Total Billed Charges,47% of Total Billed Charges,427.5,90,,913.68,Percent of Total Billed Charges,90% of Total Billed Charges,279.06,58.75,,187.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,223.25,47,,150.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,223.25,47,,150.024,Percent of Total Billed Charges,47% of Total Billed Charges,283,100,,,Case Rate,Pays based on per visit rate,43.55,115,,44.368,Fee Schedule,115% of CMS OPPS Rate,43.55,115,,44.368,Fee Schedule,115% of CMS OPPS Rate,43.55,427.5,
REMOVE FB COMPLICATE,1500034,CDM,450,RC,20525,HCPCS,Outpatient,,,399.00,399.00,,234.41,58.75,,332.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,234.41,58.75,,332.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,193.16,48.41,,273.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,2534.56,100,,156.24,fee Schedule,100% of BCBS ASC Tier Groupings ,2534.56,100,,156.24,Fee Schedule,100% of ASC Tier Groupings,187.53,47,,265.832,Percent of Total Billed Charges,47% of Total Billed Charges,2534.56,100,,156.24,Fee Schedule,100% of ASC Tier Groupings,234.41,58.75,,332.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,828.99,100,,,Fee Schedule,100% of ASC Tier Groupings,187.53,47,,265.832,Percent of Total Billed Charges,47% of Total Billed charges,828.99,100,,,Fee Schedule,100% ASC Tier Groupings,187.53,47,,265.832,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,252.01,115,,132.728,Fee Schedule,115% of CMS OPPS Rate,252.01,115,,132.728,Fee Schedule,115% of CMS OPPS Rate,187.53,2534.56,
CASIRIVI & IMDEVI INFUSION,15000344,CDM,771,RC,M0243,HCPCS,Outpatient,,,707.00,707.00,,415.36,58.75,,1130.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,415.36,58.75,,1130.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,342.26,48.41,,931.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,332.29,47,,904.28,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,415.36,58.75,,1130.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,385,100,,,Fee Schedule,100% of ASC Tier Groupings,332.29,47,,904.28,Percent of Total Billed Charges,47% of Total Billed charges,385,100,,,Fee Schedule,100% ASC Tier Groupings,332.29,47,,904.28,Percent of Total Billed Charges,47% of Total Billed Charges,30,100,,,Case Rate,Pays based on per visit rate,332.29,47,,67.68,Percent of Total Billed Charges,47% of Total Billed Charges,332.29,47,,67.68,Percent of Total Billed Charges,47% of Total Billed Charges,30,415.36,
CLSD TRMT ARTCLR FRACT FINGER,15000345,CDM,450,RC,26742,HCPCS,Outpatient,,,2405.00,2405.00,,1412.94,58.75,,172.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,1412.94,58.75,,172.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,1164.26,48.41,,142.056,Percent of Total Billed Charges,48.41% of Total Billed Charges,1481.76,100,,59.4,fee Schedule,100% of ASC Tier Groupings ,1481.76,100,,59.4,Fee Schedule,100% of ASC Tier Groupings,1130.35,47,,137.92,Percent of Total Billed Charges,47% of Total Billed Charges,1481.76,100,,59.4,Fee Schedule,100% of ASC Tier Groupings,1412.94,58.75,,172.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,603.08,100,,,Fee Schedule,100% of ASC Tier Groupings,1130.35,47,,137.92,Percent of Total Billed Charges,47% of Total Billed charges,603.08,100,,,Fee Schedule,100% ASC Tier Groupings,1130.35,47,,137.92,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,348.61,115,,46.248,Fee Schedule,115% of CMS OPPS Rate,348.61,115,,46.248,Fee Schedule,115% of CMS OPPS Rate,348.61,1481.76,
SKIN TAG REM,15000346,CDM,450,RC,11200,HCPCS,Outpatient,,,366.80,366.80,,215.5,58.75,,428.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,215.5,58.75,,428.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,177.57,48.41,,352.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,248.4,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,248.4,Fee Schedule,100% of ASC Tier Groupings,172.4,47,,342.536,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,248.4,Fee Schedule,100% of ASC Tier Groupings,215.5,58.75,,428.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,172.4,47,,342.536,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,172.4,47,,342.536,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.79,115,,81.216,Fee Schedule,115% of CMS OPPS Rate,77.79,115,,81.216,Fee Schedule,115% of CMS OPPS Rate,77.79,215.5,
EXCISION BENIGN>4.0,1500042,CDM,450,RC,11446,HCPCS,Outpatient,,,911.00,911.00,,535.21,58.75,,81.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,535.21,58.75,,81.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,441.02,48.41,,67.312,Percent of Total Billed Charges,48.41% of Total Billed Charges,2534.56,100,,745.2,fee Schedule,100% of ASC Tier Groupings ,2534.56,100,,745.2,Fee Schedule,100% of ASC Tier Groupings,428.17,47,,65.352,Percent of Total Billed Charges,47% of Total Billed Charges,2534.56,100,,745.2,Fee Schedule,100% of ASC Tier Groupings,535.21,58.75,,81.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,828.99,100,,,Fee Schedule,100% of ASC Tier Groupings,428.17,47,,65.352,Percent of Total Billed Charges,47% of Total Billed charges,828.99,100,,,Fee Schedule,100% ASC Tier Groupings,428.17,47,,65.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,324.92,115,,6.96,Fee Schedule,115% of CMS OPPS Rate,324.92,115,,6.96,Fee Schedule,115% of CMS OPPS Rate,324.92,2534.56,
I&D ABSC SIM SKIN SQ,1500087,CDM,450,RC,10060,HCPCS,Outpatient,,,173.80,173.80,,102.11,58.75,,122.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,102.11,58.75,,122.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.14,48.41,,100.96,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,571.032,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,571.032,Fee Schedule,100% of ASC Tier Groupings,81.69,47,,98.024,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,571.032,Fee Schedule,100% of ASC Tier Groupings,102.11,58.75,,122.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.17,100,,,Fee Schedule,100% of ASC Tier Groupings,81.69,47,,98.024,Percent of Total Billed Charges,47% of Total Billed charges,64.17,100,,,Fee Schedule,100% ASC Tier Groupings,81.69,47,,98.024,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,108.34,115,,12.032,Fee Schedule,115% of CMS OPPS Rate,108.34,115,,12.032,Fee Schedule,115% of CMS OPPS Rate,64.17,191.52,
I&D ABS COMP/MULTI,1500088,CDM,450,RC,10061,HCPCS,Outpatient,,,260.70,260.70,,153.16,58.75,,680.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,153.16,58.75,,680.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,126.2,48.41,,560.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,342,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,342,Fee Schedule,100% of ASC Tier Groupings,122.53,47,,544.072,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,342,Fee Schedule,100% of ASC Tier Groupings,153.16,58.75,,680.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.94,100,,,Fee Schedule,100% of ASC Tier Groupings,122.53,47,,544.072,Percent of Total Billed Charges,47% of Total Billed charges,96.94,100,,,Fee Schedule,100% ASC Tier Groupings,122.53,47,,544.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,186.81,115,,30.024,Fee Schedule,115% of CMS OPPS Rate,186.81,115,,30.024,Fee Schedule,115% of CMS OPPS Rate,96.94,349.44,
REM FB COMP SQ&INCSN,1500089,CDM,450,RC,10121,HCPCS,Outpatient,,,1447.00,1447.00,,850.11,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,850.11,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,700.49,48.41,,116.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,1500.8,100,,254.16,fee Schedule,100% of ASC Tier Groupings ,1500.8,100,,254.16,Fee Schedule,100% of ASC Tier Groupings,680.09,47,,112.8,Percent of Total Billed Charges,47% of Total Billed Charges,1500.8,100,,254.16,Fee Schedule,100% of ASC Tier Groupings,850.11,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,494.68,100,,,Fee Schedule,100% of ASC Tier Groupings,680.09,47,,112.8,Percent of Total Billed Charges,47% of Total Billed charges,494.68,100,,,Fee Schedule,100% ASC Tier Groupings,680.09,47,,112.8,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,186.85,115,,54.144,Fee Schedule,115% of CMS OPPS Rate,186.85,115,,54.144,Fee Schedule,115% of CMS OPPS Rate,186.85,1500.8,
SIM RP LAC F 5.1-7.5,1500095,CDM,450,RC,12014,HCPCS,Outpatient,,,300.00,300.00,,176.25,58.75,,596.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,176.25,58.75,,596.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.23,48.41,,491.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,46.08,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,46.08,Fee Schedule,100% of ASC Tier Groupings,141,47,,477.144,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,46.08,Fee Schedule,100% of ASC Tier Groupings,176.25,58.75,,596.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,141,47,,477.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,141,47,,477.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,75.37,115,,40.536,Fee Schedule,115% of CMS OPPS Rate,75.37,115,,40.536,Fee Schedule,115% of CMS OPPS Rate,75.37,191.52,
CRITICAL CARE 1ST HR,1500096,CDM,450,RC,99291,HCPCS,Outpatient,,,1269.00,1269.00,,745.54,58.75,,101.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,745.54,58.75,,101.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,614.32,48.41,,84.04,Percent of Total Billed Charges,48.41% of Total Billed Charges,1142.1,90,,108.72,Percent of Total Billed Charges,90% of Total Billed Charges,1142.1,90,,108.72,Percent of Total Billed Charges,90% of Total Billed Charges,596.43,47,,81.592,Percent of Total Billed Charges,47% of Total Billed Charges,1142.1,90,,108.72,Percent of Total Billed Charges,90% of Total Billed Charges,745.54,58.75,,101.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,596.43,47,,81.592,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,596.43,47,,81.592,Percent of Total Billed Charges,47% of Total Billed Charges,2000,100,,,Case Rate,Pays based on per visit rate,221.29,115,,51.136,Fee Schedule,115% of CMS OPPS Rate,221.29,115,,51.136,Fee Schedule,115% of CMS OPPS Rate,221.29,2000,
CRIT C EA ADD 30 MIN,1500097,CDM,450,RC,99292,HCPCS,Outpatient,,,217.00,217.00,,127.49,58.75,,101.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,127.49,58.75,,101.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,105.05,48.41,,83.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,195.3,90,,75.6,Percent of Total Billed Charges,90% of Total Billed Charges,195.3,90,,75.6,Percent of Total Billed Charges,90% of Total Billed Charges,101.99,47,,81.216,Percent of Total Billed Charges,47% of Total Billed Charges,195.3,90,,75.6,Percent of Total Billed Charges,90% of Total Billed Charges,127.49,58.75,,101.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,101.99,47,,81.216,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,101.99,47,,81.216,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,110.77,115,,25.568,Fee Schedule,115% of CMS OPPS Rate,110.77,115,,25.568,Fee Schedule,115% of CMS OPPS Rate,101.99,195.3,
THER INJ SUBC/INTRAM,1500098,CDM,260,RC,96372,HCPCS,Outpatient,,,216.00,216.00,,126.9,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,126.9,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,104.57,48.41,,31.76,Percent of Total Billed Charges,48.41% of Total Billed Charges,58.05,100,,171.072,fee Schedule,100% of BCBS fee schedule,58.05,100,,171.072,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,101.52,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,58.05,100,,171.072,Fee Schedule,100% of BCBS PPO fee schedule,126.9,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,101.52,47,,30.832,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,101.52,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,14.51,115,,14.888,Fee Schedule,115% of CMS OPPS Rate,14.51,115,,14.888,Fee Schedule,115% of CMS OPPS Rate,14.51,150,
THER INJ INTRA-ARTER,1500099,CDM,450,RC,,,Outpatient,,,82.00,82.00,,48.18,58.75,,139.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.18,58.75,,139.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.7,48.41,,115.024,Percent of Total Billed Charges,48.41% of Total Billed Charges,73.8,90,,84.96,Percent of Total Billed Charges,90% of Total Billed Charges,73.8,90,,84.96,Percent of Total Billed Charges,90% of Total Billed Charges,38.54,47,,111.672,Percent of Total Billed Charges,47% of Total Billed Charges,73.8,90,,84.96,Percent of Total Billed Charges,90% of Total Billed Charges,48.18,58.75,,139.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.54,47,,111.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,38.54,47,,111.672,Percent of Total Billed Charges,47% of Total Billed Charges,2000,100,,,Case Rate,Pays based on per visit rate,38.54,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,38.54,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,38.54,2000,
THER INJ INTRAVENOUS,1500100,CDM,260,RC,96374,HCPCS,Outpatient,,,297.00,297.00,,174.49,58.75,,38.776,Percent of Total Billed Charges,58.75% of Total Billed Charges,174.49,58.75,,38.776,Percent of Total Billed Charges,58.75% of Total Billed Charges,143.78,48.41,,31.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,176.4,100,,254.16,fee Schedule,100% of BCBS fee schedule,176.4,100,,254.16,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,139.59,47,,31.024,Percent of Total Billed Charges,47% of Total Billed Charges,176.4,100,,254.16,Fee Schedule,100% of BCBS PPO fee schedule,174.49,58.75,,38.776,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,139.59,47,,31.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,139.59,47,,31.024,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,34.27,115,,146.64,Fee Schedule,115% of CMS OPPS Rate,34.27,115,,146.64,Fee Schedule,115% of CMS OPPS Rate,34.27,176.4,
THER INJ ANTIB INTRM,1500101,CDM,450,RC,,,Outpatient,,,82.50,82.50,,48.47,58.75,,162.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.47,58.75,,162.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.94,48.41,,133.608,Percent of Total Billed Charges,48.41% of Total Billed Charges,74.25,90,,129.6,Percent of Total Billed Charges,90% of Total Billed Charges,74.25,90,,129.6,Percent of Total Billed Charges,90% of Total Billed Charges,38.78,47,,129.72,Percent of Total Billed Charges,47% of Total Billed Charges,74.25,90,,129.6,Percent of Total Billed Charges,90% of Total Billed Charges,48.47,58.75,,162.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.78,47,,129.72,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,38.78,47,,129.72,Percent of Total Billed Charges,47% of Total Billed Charges,2000,100,,,Case Rate,Pays based on per visit rate,38.78,47,,62.792,Percent of Total Billed Charges,47% of Total Billed Charges,38.78,47,,62.792,Percent of Total Billed Charges,47% of Total Billed Charges,38.78,2000,
LEVEL I W/PROCEDURE,1500102,CDM,450,RC,99281,HCPCS,Outpatient,,,345.00,345.00,,202.69,58.75,,486.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,202.69,58.75,,486.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,167.01,48.41,,400.832,Percent of Total Billed Charges,48.41% of Total Billed Charges,310.5,90,,88.56,Percent of Total Billed Charges,90% of Total Billed Charges,310.5,90,,88.56,Percent of Total Billed Charges,90% of Total Billed Charges,162.15,47,,389.16,Percent of Total Billed Charges,47% of Total Billed Charges,310.5,90,,88.56,Percent of Total Billed Charges,90% of Total Billed Charges,202.69,58.75,,486.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,162.15,47,,389.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,162.15,47,,389.16,Percent of Total Billed Charges,47% of Total Billed Charges,125,100,,,Case Rate,Pays based on per visit rate,11.79,115,,68.808,Fee Schedule,115% of CMS OPPS Rate,11.79,115,,68.808,Fee Schedule,115% of CMS OPPS Rate,11.79,310.5,
LEVEL IV W/PROCEDURE,1500103,CDM,450,RC,99284,HCPCS,Outpatient,,,1035.00,1035.00,,608.06,58.75,,372.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,608.06,58.75,,372.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,501.04,48.41,,307.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,931.5,90,,13.32,Percent of Total Billed Charges,90% of Total Billed Charges,931.5,90,,13.32,Percent of Total Billed Charges,90% of Total Billed Charges,486.45,47,,298.208,Percent of Total Billed Charges,47% of Total Billed Charges,931.5,90,,13.32,Percent of Total Billed Charges,90% of Total Billed Charges,608.06,58.75,,372.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,486.45,47,,298.208,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,486.45,47,,298.208,Percent of Total Billed Charges,47% of Total Billed Charges,1698,100,,,Case Rate,Pays based on per visit rate,125.74,115,,45.12,Fee Schedule,115% of CMS OPPS Rate,125.74,115,,45.12,Fee Schedule,115% of CMS OPPS Rate,125.74,1698,
LEVEL V W/PROCEDURE,1500104,CDM,450,RC,99285,HCPCS,Outpatient,,,793.10,793.10,,465.95,58.75,,223.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,465.95,58.75,,223.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,383.94,48.41,,183.96,Percent of Total Billed Charges,48.41% of Total Billed Charges,713.79,90,,28.512,Percent of Total Billed Charges,90% of Total Billed Charges,713.79,90,,28.512,Percent of Total Billed Charges,90% of Total Billed Charges,372.76,47,,178.6,Percent of Total Billed Charges,47% of Total Billed Charges,713.79,90,,28.512,Percent of Total Billed Charges,90% of Total Billed Charges,465.95,58.75,,223.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,372.76,47,,178.6,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,372.76,47,,178.6,Percent of Total Billed Charges,47% of Total Billed Charges,1800,100,,,Case Rate,Pays based on per visit rate,182.34,115,,52.64,Fee Schedule,115% of CMS OPPS Rate,182.34,115,,52.64,Fee Schedule,115% of CMS OPPS Rate,182.34,1800,
LEVEL II W/PROCEDURE,1500105,CDM,450,RC,99282,HCPCS,Outpatient,,,475.00,475.00,,279.06,58.75,,165.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,279.06,58.75,,165.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,229.95,48.41,,136.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,427.5,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,427.5,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,223.25,47,,132.728,Percent of Total Billed Charges,47% of Total Billed Charges,427.5,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,279.06,58.75,,165.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,223.25,47,,132.728,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,223.25,47,,132.728,Percent of Total Billed Charges,47% of Total Billed Charges,283,100,,,Case Rate,Pays based on per visit rate,43.55,115,,35.344,Fee Schedule,115% of CMS OPPS Rate,43.55,115,,35.344,Fee Schedule,115% of CMS OPPS Rate,43.55,427.5,
LEVEL III W/PROCED,1500106,CDM,450,RC,99283,HCPCS,Outpatient,,,353.00,353.00,,207.39,58.75,,265.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,207.39,58.75,,265.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,170.89,48.41,,218.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,317.7,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,317.7,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,165.91,47,,212.064,Percent of Total Billed Charges,47% of Total Billed Charges,317.7,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,207.39,58.75,,265.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,165.91,47,,212.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,165.91,47,,212.064,Percent of Total Billed Charges,47% of Total Billed Charges,739,100,,,Case Rate,Pays based on per visit rate,73.8,115,,11.656,Fee Schedule,115% of CMS OPPS Rate,73.8,115,,11.656,Fee Schedule,115% of CMS OPPS Rate,73.8,739,
BLOOD ADMINISTRATION,1500107,CDM,391,RC,36430,HCPCS,Outpatient,,,564.00,564.00,,331.35,58.75,,139.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,331.35,58.75,,139.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,273.03,48.41,,115.024,Percent of Total Billed Charges,48.41% of Total Billed Charges,424.48,100,,57.496,fee Schedule,100% of ASC Tier Groupings ,424.48,100,,57.496,Fee Schedule,100% of ASC Tier Groupings,265.08,47,,111.672,Percent of Total Billed Charges,47% of Total Billed Charges,424.48,100,,57.496,Fee Schedule,100% of ASC Tier Groupings,331.35,58.75,,139.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.31,100,,,Fee Schedule,100% of ASC Tier Groupings,265.08,47,,111.672,Percent of Total Billed Charges,47% of Total Billed charges,30.31,100,,,Fee Schedule,100% ASC Tier Groupings,265.08,47,,111.672,Percent of Total Billed Charges,47% of Total Billed Charges,350,100,,,Case Rate,Pays based on per visit rate,40.88,115,,19.552,Fee Schedule,115% of CMS OPPS Rate,40.88,115,,19.552,Fee Schedule,115% of CMS OPPS Rate,30.31,424.48,
IV INF HYDRA INITIAL,1500109,CDM,260,RC,96360,HCPCS,Outpatient,,,297.00,297.00,,174.49,58.75,,82.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,174.49,58.75,,82.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,143.78,48.41,,67.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,176.4,100,,103.68,fee Schedule,100% of BCBS fee schedule,176.4,100,,103.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,139.59,47,,65.8,Percent of Total Billed Charges,47% of Total Billed Charges,176.4,100,,103.68,Fee Schedule,100% of BCBS PPO fee schedule,174.49,58.75,,82.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,139.59,47,,65.8,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,139.59,47,,65.8,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,30.5,115,,8.648,Fee Schedule,115% of CMS OPPS Rate,30.5,115,,8.648,Fee Schedule,115% of CMS OPPS Rate,30.5,176.4,
REM FB EAR W ANES,1500111,CDM,450,RC,69205,HCPCS,Outpatient,,,175.00,175.00,,102.81,58.75,,197.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,102.81,58.75,,197.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.72,48.41,,162.928,Percent of Total Billed Charges,48.41% of Total Billed Charges,1500.8,100,,20.16,fee Schedule,100% of ASC Tier Groupings ,1500.8,100,,20.16,Fee Schedule,100% of ASC Tier Groupings,82.25,47,,158.184,Percent of Total Billed Charges,47% of Total Billed Charges,1500.8,100,,20.16,Fee Schedule,100% of ASC Tier Groupings,102.81,58.75,,197.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,494.68,100,,,Fee Schedule,100% of ASC Tier Groupings,82.25,47,,158.184,Percent of Total Billed Charges,47% of Total Billed charges,494.68,100,,,Fee Schedule,100% ASC Tier Groupings,82.25,47,,158.184,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,96.07,115,,47.752,Fee Schedule,115% of CMS OPPS Rate,96.07,115,,47.752,Fee Schedule,115% of CMS OPPS Rate,82.25,1500.8,
CL/TR/SH W/MANP-ANE,1500112,CDM,450,RC,23650,HCPCS,Outpatient,,,420.70,420.70,,247.16,58.75,,258.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,247.16,58.75,,258.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,203.66,48.41,,212.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,236.32,100,,77.616,fee Schedule,100% of ASC Tier Groupings ,236.32,100,,77.616,Fee Schedule,100% of ASC Tier Groupings,197.73,47,,206.424,Percent of Total Billed Charges,47% of Total Billed Charges,236.32,100,,77.616,Fee Schedule,100% of ASC Tier Groupings,247.16,58.75,,258.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.76,100,,,Fee Schedule,100% of ASC Tier Groupings,197.73,47,,206.424,Percent of Total Billed Charges,47% of Total Billed charges,86.76,100,,,Fee Schedule,100% ASC Tier Groupings,197.73,47,,206.424,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,313.44,115,,12.408,Fee Schedule,115% of CMS OPPS Rate,313.44,115,,12.408,Fee Schedule,115% of CMS OPPS Rate,86.76,313.44,
CL/TR/SH MANP/WANES,1500113,CDM,450,RC,23655,HCPCS,Outpatient,,,549.00,549.00,,322.54,58.75,,29.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,322.54,58.75,,29.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,265.77,48.41,,24.168,Percent of Total Billed Charges,48.41% of Total Billed Charges,1481.76,100,,97.92,fee Schedule,100% of ASC Tier Groupings ,1481.76,100,,97.92,Fee Schedule,100% of ASC Tier Groupings,258.03,47,,23.464,Percent of Total Billed Charges,47% of Total Billed Charges,1481.76,100,,97.92,Fee Schedule,100% of ASC Tier Groupings,322.54,58.75,,29.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,603.08,100,,,Fee Schedule,100% of ASC Tier Groupings,258.03,47,,23.464,Percent of Total Billed Charges,47% of Total Billed charges,603.08,100,,,Fee Schedule,100% ASC Tier Groupings,258.03,47,,23.464,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,418.4,115,,11.28,Fee Schedule,115% of CMS OPPS Rate,418.4,115,,11.28,Fee Schedule,115% of CMS OPPS Rate,258.03,1481.76,
RM FB EXT EYE CONJ,1500117,CDM,450,RC,65205,HCPCS,Outpatient,,,62.40,62.40,,36.66,58.75,,84.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.66,58.75,,84.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.21,48.41,,69.576,Percent of Total Billed Charges,48.41% of Total Billed Charges,119.84,100,,48.96,fee Schedule,100% of ASC Tier Groupings ,119.84,100,,48.96,Fee Schedule,100% of ASC Tier Groupings,29.33,47,,67.552,Percent of Total Billed Charges,47% of Total Billed Charges,119.84,100,,48.96,Fee Schedule,100% of ASC Tier Groupings,36.66,58.75,,84.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.33,47,,67.552,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,29.33,47,,67.552,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.68,115,,78.208,Fee Schedule,115% of CMS OPPS Rate,29.68,115,,78.208,Fee Schedule,115% of CMS OPPS Rate,29.33,119.84,
REM FB INTRANASAE,1500119,CDM,450,RC,30300,HCPCS,Outpatient,,,179.65,179.65,,105.54,58.75,,223.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,105.54,58.75,,223.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.97,48.41,,184.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,119.84,100,,28.512,fee Schedule,100% of ASC Tier Groupings ,119.84,100,,28.512,Fee Schedule,100% of ASC Tier Groupings,84.44,47,,179.048,Percent of Total Billed Charges,47% of Total Billed Charges,119.84,100,,28.512,Fee Schedule,100% of ASC Tier Groupings,105.54,58.75,,223.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,84.44,47,,179.048,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,84.44,47,,179.048,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,120.72,115,,38.352,Fee Schedule,115% of CMS OPPS Rate,120.72,115,,38.352,Fee Schedule,115% of CMS OPPS Rate,84.44,120.72,
RP COM SA/LEG 2.6 +,1500120,CDM,450,RC,13121,HCPCS,Outpatient,,,476.20,476.20,,279.77,58.75,,173.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,279.77,58.75,,173.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,230.53,48.41,,143.296,Percent of Total Billed Charges,48.41% of Total Billed Charges,543.2,100,,70.56,fee Schedule,100% of ASC Tier Groupings ,543.2,100,,70.56,Fee Schedule,100% of ASC Tier Groupings,223.81,47,,139.12,Percent of Total Billed Charges,47% of Total Billed Charges,543.2,100,,70.56,Fee Schedule,100% of ASC Tier Groupings,279.77,58.75,,173.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,220.47,100,,,Fee Schedule,100% of ASC Tier Groupings,223.81,47,,139.12,Percent of Total Billed Charges,47% of Total Billed charges,220.47,100,,,Fee Schedule,100% ASC Tier Groupings,223.81,47,,139.12,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,262.52,115,,186.872,Fee Schedule,115% of CMS OPPS Rate,262.52,115,,186.872,Fee Schedule,115% of CMS OPPS Rate,220.47,543.2,
REDUCTION OF ELBOW,1500121,CDM,450,RC,24640,HCPCS,Outpatient,,,370.00,370.00,,217.38,58.75,,291.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,217.38,58.75,,291.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,179.12,48.41,,240.112,Percent of Total Billed Charges,48.41% of Total Billed Charges,236.32,100,,280.8,fee Schedule,100% of ASC Tier Groupings ,236.32,100,,280.8,Fee Schedule,100% of ASC Tier Groupings,173.9,47,,233.12,Percent of Total Billed Charges,47% of Total Billed Charges,236.32,100,,280.8,Fee Schedule,100% of ASC Tier Groupings,217.38,58.75,,291.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.34,100,,,Fee Schedule,100% of ASC Tier Groupings,173.9,47,,233.12,Percent of Total Billed Charges,47% of Total Billed charges,48.34,100,,,Fee Schedule,100% ASC Tier Groupings,173.9,47,,233.12,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,81.95,115,,167.696,Fee Schedule,115% of CMS OPPS Rate,81.95,115,,167.696,Fee Schedule,115% of CMS OPPS Rate,48.34,236.32,
REMOVE FB EXT EYE,1500131,CDM,450,RC,65220,HCPCS,Outpatient,,,620.00,620.00,,364.25,58.75,,81.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,364.25,58.75,,81.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,300.14,48.41,,67.384,Percent of Total Billed Charges,48.41% of Total Billed Charges,397.6,100,,120.24,fee Schedule,100% of ASC Tier Groupings ,397.6,100,,120.24,Fee Schedule,100% of ASC Tier Groupings,291.4,47,,65.424,Percent of Total Billed Charges,47% of Total Billed Charges,397.6,100,,120.24,Fee Schedule,100% of ASC Tier Groupings,364.25,58.75,,81.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,291.4,47,,65.424,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,291.4,47,,65.424,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,41.7,115,,379.76,Fee Schedule,115% of CMS OPPS Rate,41.7,115,,379.76,Fee Schedule,115% of CMS OPPS Rate,41.7,397.6,
I&D ABSECC PALATE,1500132,CDM,450,RC,42000,HCPCS,Outpatient,,,174.00,174.00,,102.23,58.75,,767.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,102.23,58.75,,767.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.23,48.41,,632.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,222.88,100,,131.76,fee Schedule,100% of ASC Tier Groupings ,222.88,100,,131.76,Fee Schedule,100% of ASC Tier Groupings,81.78,47,,614.384,Percent of Total Billed Charges,47% of Total Billed Charges,222.88,100,,131.76,Fee Schedule,100% of ASC Tier Groupings,102.23,58.75,,767.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.05,100,,,Fee Schedule,100% of ASC Tier Groupings,81.78,47,,614.384,Percent of Total Billed Charges,47% of Total Billed charges,89.05,100,,,Fee Schedule,100% ASC Tier Groupings,81.78,47,,614.384,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,110.58,115,,7.144,Fee Schedule,115% of CMS OPPS Rate,110.58,115,,7.144,Fee Schedule,115% of CMS OPPS Rate,81.78,222.88,
REPAIR TEN/MUSCLE,1500133,CDM,450,RC,25260,HCPCS,Outpatient,,,1634.00,1634.00,,959.98,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,959.98,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,791.02,48.41,,38.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,2991.52,100,,86.4,fee Schedule,100% of ASC Tier Groupings ,2991.52,100,,86.4,Fee Schedule,100% of ASC Tier Groupings,767.98,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,2991.52,100,,86.4,Fee Schedule,100% of ASC Tier Groupings,959.98,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,1106.68,100,,,Fee Schedule,100% of ASC Tier Groupings,767.98,47,,37.6,Percent of Total Billed Charges,47% of Total Billed charges,1106.68,100,,,Fee Schedule,100% ASC Tier Groupings,767.98,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,650.26,115,,6.768,Fee Schedule,115% of CMS OPPS Rate,650.26,115,,6.768,Fee Schedule,115% of CMS OPPS Rate,650.26,2991.52,
DEBRID BURN WO ANES,1500134,CDM,450,RC,16020,HCPCS,Outpatient,,,100.00,100.00,,58.75,58.75,,337.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.75,58.75,,337.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.41,48.41,,278.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,100.8,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,100.8,Fee Schedule,100% of ASC Tier Groupings,47,47,,270.344,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,100.8,Fee Schedule,100% of ASC Tier Groupings,58.75,58.75,,337.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47,47,,270.344,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47,47,,270.344,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,56.1,115,,63.544,Fee Schedule,115% of CMS OPPS Rate,56.1,115,,63.544,Fee Schedule,115% of CMS OPPS Rate,47,191.52,
RP LAC TESTICLES/SCR,1500136,CDM,450,RC,54670,HCPCS,Outpatient,,,719.00,719.00,,422.41,58.75,,286.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,422.41,58.75,,286.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,348.07,48.41,,236.24,Percent of Total Billed Charges,48.41% of Total Billed Charges,1936.48,100,,67.68,fee Schedule,100% of ASC Tier Groupings ,1936.48,100,,67.68,Fee Schedule,100% of ASC Tier Groupings,337.93,47,,229.36,Percent of Total Billed Charges,47% of Total Billed Charges,1936.48,100,,67.68,Fee Schedule,100% of ASC Tier Groupings,422.41,58.75,,286.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,1162.22,100,,,Fee Schedule,100% of ASC Tier Groupings,337.93,47,,229.36,Percent of Total Billed Charges,47% of Total Billed charges,1162.22,100,,,Fee Schedule,100% ASC Tier Groupings,337.93,47,,229.36,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,421,115,,0.752,Fee Schedule,115% of CMS OPPS Rate,421,115,,0.752,Fee Schedule,115% of CMS OPPS Rate,337.93,1936.48,
CL FX/THUMB W/MANIP,1500138,CDM,450,RC,26645,HCPCS,Outpatient,,,610.00,610.00,,358.38,58.75,,50.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,358.38,58.75,,50.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,295.3,48.41,,41.824,Percent of Total Billed Charges,48.41% of Total Billed Charges,1481.76,100,,22.32,fee Schedule,100% of ASC Tier Groupings ,1481.76,100,,22.32,Fee Schedule,100% of ASC Tier Groupings,286.7,47,,40.608,Percent of Total Billed Charges,47% of Total Billed Charges,1481.76,100,,22.32,Fee Schedule,100% of ASC Tier Groupings,358.38,58.75,,50.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,603.08,100,,,Fee Schedule,100% of ASC Tier Groupings,286.7,47,,40.608,Percent of Total Billed Charges,47% of Total Billed charges,603.08,100,,,Fee Schedule,100% ASC Tier Groupings,286.7,47,,40.608,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,409.15,115,,62.04,Fee Schedule,115% of CMS OPPS Rate,409.15,115,,62.04,Fee Schedule,115% of CMS OPPS Rate,286.7,1481.76,
FB REMOV EXT EYE COJ,1500140,CDM,450,RC,65205,HCPCS,Outpatient,,,108.00,108.00,,63.45,58.75,,460.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,63.45,58.75,,460.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,52.28,48.41,,379.144,Percent of Total Billed Charges,48.41% of Total Billed Charges,119.84,100,,37.44,fee Schedule,100% of ASC Tier Groupings ,119.84,100,,37.44,Fee Schedule,100% of ASC Tier Groupings,50.76,47,,368.104,Percent of Total Billed Charges,47% of Total Billed Charges,119.84,100,,37.44,Fee Schedule,100% of ASC Tier Groupings,63.45,58.75,,460.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,50.76,47,,368.104,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,50.76,47,,368.104,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.68,115,,7.448,Fee Schedule,115% of CMS OPPS Rate,29.68,115,,7.448,Fee Schedule,115% of CMS OPPS Rate,29.68,119.84,
OPEN TXFX/DISL THUMB,1500142,CDM,450,RC,26665,HCPCS,Outpatient,,,979.00,979.00,,575.16,58.75,,198.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,575.16,58.75,,198.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,473.93,48.41,,163.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,2991.52,100,,16.56,fee Schedule,100% of ASC Tier Groupings ,2991.52,100,,16.56,Fee Schedule,100% of ASC Tier Groupings,460.13,47,,158.8,Percent of Total Billed Charges,47% of Total Billed Charges,2991.52,100,,16.56,Fee Schedule,100% of ASC Tier Groupings,575.16,58.75,,198.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,1106.68,100,,,Fee Schedule,100% of ASC Tier Groupings,460.13,47,,158.8,Percent of Total Billed Charges,47% of Total Billed charges,1106.68,100,,,Fee Schedule,100% ASC Tier Groupings,460.13,47,,158.8,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,644.53,115,,21.504,Fee Schedule,115% of CMS OPPS Rate,644.53,115,,21.504,Fee Schedule,115% of CMS OPPS Rate,460.13,2991.52,
CLSD TXFX FINGER/THUMB,1500144,CDM,450,RC,26725,HCPCS,Outpatient,,,422.35,422.35,,248.13,58.75,,210.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,248.13,58.75,,210.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,204.46,48.41,,173.504,Percent of Total Billed Charges,48.41% of Total Billed Charges,236.32,100,,91.44,fee Schedule,100% of ASC Tier Groupings ,236.32,100,,91.44,Fee Schedule,100% of ASC Tier Groupings,198.5,47,,168.448,Percent of Total Billed Charges,47% of Total Billed Charges,236.32,100,,91.44,Fee Schedule,100% of ASC Tier Groupings,248.13,58.75,,210.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.76,100,,,Fee Schedule,100% of ASC Tier Groupings,198.5,47,,168.448,Percent of Total Billed Charges,47% of Total Billed charges,86.76,100,,,Fee Schedule,100% ASC Tier Groupings,198.5,47,,168.448,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,317.66,115,,5.264,Fee Schedule,115% of CMS OPPS Rate,317.66,115,,5.264,Fee Schedule,115% of CMS OPPS Rate,86.76,317.66,
JOINT INJ,1500146,CDM,450,RC,20610,HCPCS,Outpatient,,,448.00,448.00,,263.2,58.75,,117.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,263.2,58.75,,117.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,216.88,48.41,,96.432,Percent of Total Billed Charges,48.41% of Total Billed Charges,286.72,100,,23.76,fee Schedule,100% of ASC Tier Groupings ,286.72,100,,23.76,Fee Schedule,100% of ASC Tier Groupings,210.56,47,,93.624,Percent of Total Billed Charges,47% of Total Billed Charges,286.72,100,,23.76,Fee Schedule,100% of ASC Tier Groupings,263.2,58.75,,117.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.57,100,,,Fee Schedule,100% of ASC Tier Groupings,210.56,47,,93.624,Percent of Total Billed Charges,47% of Total Billed charges,27.57,100,,,Fee Schedule,100% ASC Tier Groupings,210.56,47,,93.624,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.97,115,,5.008,Fee Schedule,115% of CMS OPPS Rate,45.97,115,,5.008,Fee Schedule,115% of CMS OPPS Rate,27.57,286.72,
LAC TO TONGUE 2.5CM,1500148,CDM,450,RC,41250,HCPCS,Outpatient,,,249.00,249.00,,146.29,58.75,,39.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,146.29,58.75,,39.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,120.54,48.41,,32.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,119.84,100,,21.6,fee Schedule,100% of ASC Tier Groupings ,119.84,100,,21.6,Fee Schedule,100% of ASC Tier Groupings,117.03,47,,31.4,Percent of Total Billed Charges,47% of Total Billed Charges,119.84,100,,21.6,Fee Schedule,100% of ASC Tier Groupings,146.29,58.75,,39.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,117.03,47,,31.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,117.03,47,,31.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,154.95,115,,6.52,Fee Schedule,115% of CMS OPPS Rate,154.95,115,,6.52,Fee Schedule,115% of CMS OPPS Rate,117.03,154.95,
LAC TONGUE 2.5CM PF,1500149,CDM,981,RC,41250,HCPCS,Outpatient,,,636.95,636.95,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
ASPIRATION/INJ JOINT,1500150,CDM,450,RC,20610,HCPCS,Outpatient,,,83.50,83.50,,49.06,58.75,,27.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.06,58.75,,27.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.42,48.41,,22.464,Percent of Total Billed Charges,48.41% of Total Billed Charges,286.72,100,,149.76,fee Schedule,100% of ASC Tier Groupings ,286.72,100,,149.76,Fee Schedule,100% of ASC Tier Groupings,39.25,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,286.72,100,,149.76,Fee Schedule,100% of ASC Tier Groupings,49.06,58.75,,27.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.57,100,,,Fee Schedule,100% of ASC Tier Groupings,39.25,47,,21.808,Percent of Total Billed Charges,47% of Total Billed charges,27.57,100,,,Fee Schedule,100% ASC Tier Groupings,39.25,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.97,115,,4.096,Fee Schedule,115% of CMS OPPS Rate,45.97,115,,4.096,Fee Schedule,115% of CMS OPPS Rate,27.57,286.72,
REM SINGLE NAILW/BL,1500152,CDM,450,RC,11730,HCPCS,Outpatient,,,300.00,300.00,,176.25,58.75,,267.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,176.25,58.75,,267.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.23,48.41,,220.496,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,73.44,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,73.44,Fee Schedule,100% of ASC Tier Groupings,141,47,,214.072,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,73.44,Fee Schedule,100% of ASC Tier Groupings,176.25,58.75,,267.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,141,47,,214.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,141,47,,214.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.95,115,,13.192,Fee Schedule,115% of CMS OPPS Rate,55.95,115,,13.192,Fee Schedule,115% of CMS OPPS Rate,55.95,191.52,
REM ADDL NAIL W/BLOC,1500154,CDM,450,RC,11732,HCPCS,Outpatient,,,58.00,58.00,,34.08,58.75,,102.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.08,58.75,,102.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.08,48.41,,84.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27.26,47,,82.344,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,34.08,58.75,,102.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.26,47,,82.344,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,27.26,47,,82.344,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.58,115,,14.288,Fee Schedule,115% of CMS OPPS Rate,17.58,115,,14.288,Fee Schedule,115% of CMS OPPS Rate,17.58,34.08,
CLSD REDT ELBOWW AN,1500156,CDM,450,RC,24300,HCPCS,Outpatient,,,569.35,569.35,,334.49,58.75,,23.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,334.49,58.75,,23.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,275.62,48.41,,19.368,Percent of Total Billed Charges,48.41% of Total Billed Charges,1481.76,100,,321.12,fee Schedule,100% of ASC Tier Groupings ,1481.76,100,,321.12,Fee Schedule,100% of ASC Tier Groupings,267.59,47,,18.8,Percent of Total Billed Charges,47% of Total Billed Charges,1481.76,100,,321.12,Fee Schedule,100% of ASC Tier Groupings,334.49,58.75,,23.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,603.08,100,,,Fee Schedule,100% of ASC Tier Groupings,267.59,47,,18.8,Percent of Total Billed Charges,47% of Total Billed charges,603.08,100,,,Fee Schedule,100% ASC Tier Groupings,267.59,47,,18.8,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,451.81,115,,26.32,Fee Schedule,115% of CMS OPPS Rate,451.81,115,,26.32,Fee Schedule,115% of CMS OPPS Rate,267.59,1481.76,
SIM I&D MOUTH /AUTH,1500159,CDM,450,RC,40800,HCPCS,Outpatient,,,219.00,219.00,,128.66,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,128.66,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,106.02,48.41,,49.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,667.52,100,,727.2,fee Schedule,100% of ASC Tier Groupings ,667.52,100,,727.2,Fee Schedule,100% of ASC Tier Groupings,102.93,47,,47.752,Percent of Total Billed Charges,47% of Total Billed Charges,667.52,100,,727.2,Fee Schedule,100% of ASC Tier Groupings,128.66,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,129.98,100,,,Fee Schedule,100% of ASC Tier Groupings,102.93,47,,47.752,Percent of Total Billed Charges,47% of Total Billed charges,129.98,100,,,Fee Schedule,100% ASC Tier Groupings,102.93,47,,47.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,121.51,115,,6.392,Fee Schedule,115% of CMS OPPS Rate,121.51,115,,6.392,Fee Schedule,115% of CMS OPPS Rate,102.93,667.52,
SPLINT FINGER,1500163,CDM,450,RC,29130,HCPCS,Outpatient,,,50.00,50.00,,29.38,58.75,,62.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.38,58.75,,62.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.21,48.41,,51.512,Percent of Total Billed Charges,48.41% of Total Billed Charges,60.48,100,,13.68,fee Schedule,100% of ASC Tier Groupings ,60.48,100,,13.68,Fee Schedule,100% of ASC Tier Groupings,23.5,47,,50.008,Percent of Total Billed Charges,47% of Total Billed Charges,60.48,100,,13.68,Fee Schedule,100% of ASC Tier Groupings,29.38,58.75,,62.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.5,47,,50.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.5,47,,50.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.42,115,,24.44,Fee Schedule,115% of CMS OPPS Rate,29.42,115,,24.44,Fee Schedule,115% of CMS OPPS Rate,23.5,60.48,
SPLINT LONG LEG,1500165,CDM,450,RC,29505,HCPCS,Outpatient,,,127.00,127.00,,74.61,58.75,,72.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.61,58.75,,72.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.48,48.41,,59.64,Percent of Total Billed Charges,48.41% of Total Billed Charges,146.72,100,,12.96,fee Schedule,100% of ASC Tier Groupings ,146.72,100,,12.96,Fee Schedule,100% of ASC Tier Groupings,59.69,47,,57.904,Percent of Total Billed Charges,47% of Total Billed Charges,146.72,100,,12.96,Fee Schedule,100% of ASC Tier Groupings,74.61,58.75,,72.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.79,100,,,Fee Schedule,100% of ASC Tier Groupings,59.69,47,,57.904,Percent of Total Billed Charges,47% of Total Billed charges,47.79,100,,,Fee Schedule,100% ASC Tier Groupings,59.69,47,,57.904,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,53.44,115,,7.16,Fee Schedule,115% of CMS OPPS Rate,53.44,115,,7.16,Fee Schedule,115% of CMS OPPS Rate,47.79,146.72,
SPLINT SHORT LEG,1500167,CDM,450,RC,29515,HCPCS,Outpatient,,,133.00,133.00,,78.14,58.75,,62.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,78.14,58.75,,62.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.39,48.41,,51.512,Percent of Total Billed Charges,48.41% of Total Billed Charges,146.72,100,,121.68,fee Schedule,100% of ASC Tier Groupings ,146.72,100,,121.68,Fee Schedule,100% of ASC Tier Groupings,62.51,47,,50.008,Percent of Total Billed Charges,47% of Total Billed Charges,146.72,100,,121.68,Fee Schedule,100% of ASC Tier Groupings,78.14,58.75,,62.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.86,100,,,Fee Schedule,100% of ASC Tier Groupings,62.51,47,,50.008,Percent of Total Billed Charges,47% of Total Billed charges,33.86,100,,,Fee Schedule,100% ASC Tier Groupings,62.51,47,,50.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,50.9,115,,6.864,Fee Schedule,115% of CMS OPPS Rate,50.9,115,,6.864,Fee Schedule,115% of CMS OPPS Rate,33.86,146.72,
SPLINT LONG ARM,1500169,CDM,450,RC,29105,HCPCS,Outpatient,,,154.00,154.00,,90.48,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,90.48,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.55,48.41,,24.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,146.72,100,,1.44,fee Schedule,100% of ASC Tier Groupings ,146.72,100,,1.44,Fee Schedule,100% of ASC Tier Groupings,72.38,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,146.72,100,,1.44,Fee Schedule,100% of ASC Tier Groupings,90.48,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.59,100,,,Fee Schedule,100% of ASC Tier Groupings,72.38,47,,24.064,Percent of Total Billed Charges,47% of Total Billed charges,39.59,100,,,Fee Schedule,100% ASC Tier Groupings,72.38,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,42.11,115,,6.392,Fee Schedule,115% of CMS OPPS Rate,42.11,115,,6.392,Fee Schedule,115% of CMS OPPS Rate,39.59,146.72,
SPLINT LONG ARMPF,1500170,CDM,981,RC,29105,HCPCS,Outpatient,,,277.81,277.81,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
SPLINT SHORT ARM,1500171,CDM,450,RC,29125,HCPCS,Outpatient,,,133.00,133.00,,78.14,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,78.14,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.39,48.41,,50.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,119.84,100,,14.256,fee Schedule,100% of ASC Tier Groupings ,119.84,100,,14.256,Fee Schedule,100% of ASC Tier Groupings,62.51,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,119.84,100,,14.256,Fee Schedule,100% of ASC Tier Groupings,78.14,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,62.51,47,,48.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,62.51,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.93,115,,82.704,Fee Schedule,115% of CMS OPPS Rate,40.93,115,,82.704,Fee Schedule,115% of CMS OPPS Rate,40.93,119.84,
ASSESSMENT RN MILLCK,1500173,CDM,450,RC,99282,HCPCS,Outpatient,,,64.00,64.00,,37.6,58.75,,210.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.6,58.75,,210.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.98,48.41,,173.504,Percent of Total Billed Charges,48.41% of Total Billed Charges,57.6,90,,41.184,Percent of Total Billed Charges,90% of Total Billed Charges,57.6,90,,41.184,Percent of Total Billed Charges,90% of Total Billed Charges,30.08,47,,168.448,Percent of Total Billed Charges,47% of Total Billed Charges,57.6,90,,41.184,Percent of Total Billed Charges,90% of Total Billed Charges,37.6,58.75,,210.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.08,47,,168.448,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,30.08,47,,168.448,Percent of Total Billed Charges,47% of Total Billed Charges,283,100,,,Case Rate,Pays based on per visit rate,43.55,115,,7.52,Fee Schedule,115% of CMS OPPS Rate,43.55,115,,7.52,Fee Schedule,115% of CMS OPPS Rate,30.08,283,
CLOSED REDUCT FINGER,1500175,CDM,450,RC,26770,HCPCS,Outpatient,,,379.00,379.00,,222.66,58.75,,29.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,222.66,58.75,,29.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,183.47,48.41,,24.008,Percent of Total Billed Charges,48.41% of Total Billed Charges,236.32,100,,10.08,fee Schedule,100% of ASC Tier Groupings ,236.32,100,,10.08,Fee Schedule,100% of ASC Tier Groupings,178.13,47,,23.312,Percent of Total Billed Charges,47% of Total Billed Charges,236.32,100,,10.08,Fee Schedule,100% of ASC Tier Groupings,222.66,58.75,,29.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.76,100,,,Fee Schedule,100% of ASC Tier Groupings,178.13,47,,23.312,Percent of Total Billed Charges,47% of Total Billed charges,86.76,100,,,Fee Schedule,100% ASC Tier Groupings,178.13,47,,23.312,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,275.83,115,,4.096,Fee Schedule,115% of CMS OPPS Rate,275.83,115,,4.096,Fee Schedule,115% of CMS OPPS Rate,86.76,275.83,
FB REM SIM UPARM/ELB,1500176,CDM,450,RC,24200,HCPCS,Outpatient,,,130.00,130.00,,76.38,58.75,,76.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.38,58.75,,76.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.93,48.41,,62.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,1500.8,100,,9.584,fee Schedule,100% of ASC Tier Groupings ,1500.8,100,,9.584,Fee Schedule,100% of ASC Tier Groupings,61.1,47,,61.04,Percent of Total Billed Charges,47% of Total Billed Charges,1500.8,100,,9.584,Fee Schedule,100% of ASC Tier Groupings,76.38,58.75,,76.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,121.8,100,,,Fee Schedule,100% of ASC Tier Groupings,61.1,47,,61.04,Percent of Total Billed Charges,47% of Total Billed charges,121.8,100,,,Fee Schedule,100% ASC Tier Groupings,61.1,47,,61.04,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,145.66,115,,8.648,Fee Schedule,115% of CMS OPPS Rate,145.66,115,,8.648,Fee Schedule,115% of CMS OPPS Rate,61.1,1500.8,
TRIGGERING 1-2 MUSCL,1500182,CDM,450,RC,20552,HCPCS,Outpatient,,,448.00,448.00,,263.2,58.75,,125.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,263.2,58.75,,125.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,216.88,48.41,,103.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,286.72,100,,12.48,fee Schedule,100% of ASC Tier Groupings ,286.72,100,,12.48,Fee Schedule,100% of ASC Tier Groupings,210.56,47,,100.32,Percent of Total Billed Charges,47% of Total Billed Charges,286.72,100,,12.48,Fee Schedule,100% of ASC Tier Groupings,263.2,58.75,,125.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.94,100,,,Fee Schedule,100% of ASC Tier Groupings,210.56,47,,100.32,Percent of Total Billed Charges,47% of Total Billed charges,22.94,100,,,Fee Schedule,100% ASC Tier Groupings,210.56,47,,100.32,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.41,115,,12.656,Fee Schedule,115% of CMS OPPS Rate,37.41,115,,12.656,Fee Schedule,115% of CMS OPPS Rate,22.94,286.72,
IV INJ DIFFOR >1,1500183,CDM,260,RC,96375,HCPCS,Outpatient,,,62.00,62.00,,36.43,58.75,,210.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.43,58.75,,210.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.01,48.41,,173.504,Percent of Total Billed Charges,48.41% of Total Billed Charges,36.59,100,,14.4,fee Schedule,100% of BCBS fee schedule,36.59,100,,14.4,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,29.14,47,,168.448,Percent of Total Billed Charges,47% of Total Billed Charges,36.59,100,,14.4,Fee Schedule,100% of BCBS PPO fee schedule,36.43,58.75,,210.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.14,47,,168.448,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,29.14,47,,168.448,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,14.47,115,,11.28,Fee Schedule,115% of CMS OPPS Rate,14.47,115,,11.28,Fee Schedule,115% of CMS OPPS Rate,14.47,150,
I & D EYELID,1500184,CDM,450,RC,67700,HCPCS,Outpatient,,,162.35,162.35,,95.38,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,95.38,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,78.59,48.41,,29.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,295.68,100,,7.84,fee Schedule,100% of ASC Tier Groupings ,295.68,100,,7.84,Fee Schedule,100% of ASC Tier Groupings,76.3,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,295.68,100,,7.84,Fee Schedule,100% of ASC Tier Groupings,95.38,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,110.12,100,,,Fee Schedule,100% of ASC Tier Groupings,76.3,47,,28.2,Percent of Total Billed Charges,47% of Total Billed charges,110.12,100,,,Fee Schedule,100% ASC Tier Groupings,76.3,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,117.4,115,,9.512,Fee Schedule,115% of CMS OPPS Rate,117.4,115,,9.512,Fee Schedule,115% of CMS OPPS Rate,76.3,295.68,
BURN < 5 BSA,1500186,CDM,450,RC,16020,HCPCS,Outpatient,,,266.80,266.80,,156.75,58.75,,70.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,156.75,58.75,,70.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,129.16,48.41,,58.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,25.264,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,25.264,Fee Schedule,100% of ASC Tier Groupings,125.4,47,,56.776,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,25.264,Fee Schedule,100% of ASC Tier Groupings,156.75,58.75,,70.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,125.4,47,,56.776,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,125.4,47,,56.776,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,56.1,115,,3.008,Fee Schedule,115% of CMS OPPS Rate,56.1,115,,3.008,Fee Schedule,115% of CMS OPPS Rate,56.1,191.52,
"INJ/ASP KNEE,HIP,SHO",1500187,CDM,450,RC,20610,HCPCS,Outpatient,,,448.00,448.00,,263.2,58.75,,49.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,263.2,58.75,,49.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,216.88,48.41,,40.664,Percent of Total Billed Charges,48.41% of Total Billed Charges,286.72,100,,27.36,fee Schedule,100% of ASC Tier Groupings ,286.72,100,,27.36,Fee Schedule,100% of ASC Tier Groupings,210.56,47,,39.48,Percent of Total Billed Charges,47% of Total Billed Charges,286.72,100,,27.36,Fee Schedule,100% of ASC Tier Groupings,263.2,58.75,,49.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.57,100,,,Fee Schedule,100% of ASC Tier Groupings,210.56,47,,39.48,Percent of Total Billed Charges,47% of Total Billed charges,27.57,100,,,Fee Schedule,100% ASC Tier Groupings,210.56,47,,39.48,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.97,115,,5.376,Fee Schedule,115% of CMS OPPS Rate,45.97,115,,5.376,Fee Schedule,115% of CMS OPPS Rate,27.57,286.72,
DEBRID SKIN FULTHKN,1500189,CDM,450,RC,11042,HCPCS,Outpatient,,,75.00,75.00,,44.06,58.75,,111.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.06,58.75,,111.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.31,48.41,,92.016,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,50.4,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,50.4,Fee Schedule,100% of ASC Tier Groupings,35.25,47,,89.336,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,50.4,Fee Schedule,100% of ASC Tier Groupings,44.06,58.75,,111.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,35.25,47,,89.336,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,35.25,47,,89.336,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,61.82,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,61.82,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,35.25,349.44,
HEMORRHOID EXT THROM,1500191,CDM,450,RC,,,Outpatient,,,151.00,151.00,,88.71,58.75,,55.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,88.71,58.75,,55.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.1,48.41,,45.696,Percent of Total Billed Charges,48.41% of Total Billed Charges,135.9,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,135.9,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,70.97,47,,44.368,Percent of Total Billed Charges,47% of Total Billed Charges,135.9,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,88.71,58.75,,55.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,70.97,47,,44.368,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,70.97,47,,44.368,Percent of Total Billed Charges,47% of Total Billed Charges,2000,100,,,Case Rate,Pays based on per visit rate,70.97,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,70.97,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,70.97,2000,
BLOOD ALCOHOL-ER,1500193,CDM,450,RC,,,Outpatient,,,105.00,105.00,,61.69,58.75,,165.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.69,58.75,,165.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.83,48.41,,136.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,94.5,90,,46.8,Percent of Total Billed Charges,90% of Total Billed Charges,94.5,90,,46.8,Percent of Total Billed Charges,90% of Total Billed Charges,49.35,47,,132.728,Percent of Total Billed Charges,47% of Total Billed Charges,94.5,90,,46.8,Percent of Total Billed Charges,90% of Total Billed Charges,61.69,58.75,,165.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.35,47,,132.728,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,49.35,47,,132.728,Percent of Total Billed Charges,47% of Total Billed Charges,2000,100,,,Case Rate,Pays based on per visit rate,49.35,47,,43.992,Percent of Total Billed Charges,47% of Total Billed Charges,49.35,47,,43.992,Percent of Total Billed Charges,47% of Total Billed Charges,49.35,2000,
FB REMOVAL FT SUBC,1500194,CDM,450,RC,,,Outpatient,,,237.60,237.60,,139.59,58.75,,84.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,139.59,58.75,,84.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,115.02,48.41,,69.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,213.84,90,,13.72,Percent of Total Billed Charges,90% of Total Billed Charges,213.84,90,,13.72,Percent of Total Billed Charges,90% of Total Billed Charges,111.67,47,,67.68,Percent of Total Billed Charges,47% of Total Billed Charges,213.84,90,,13.72,Percent of Total Billed Charges,90% of Total Billed Charges,139.59,58.75,,84.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,111.67,47,,67.68,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,111.67,47,,67.68,Percent of Total Billed Charges,47% of Total Billed Charges,2000,100,,,Case Rate,Pays based on per visit rate,111.67,47,,24.44,Percent of Total Billed Charges,47% of Total Billed Charges,111.67,47,,24.44,Percent of Total Billed Charges,47% of Total Billed Charges,111.67,2000,
THORACENTESIS,1500196,CDM,450,RC,,,Outpatient,,,118.00,118.00,,69.33,58.75,,57.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.33,58.75,,57.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.12,48.41,,47.632,Percent of Total Billed Charges,48.41% of Total Billed Charges,106.2,90,,13.144,Percent of Total Billed Charges,90% of Total Billed Charges,106.2,90,,13.144,Percent of Total Billed Charges,90% of Total Billed Charges,55.46,47,,46.248,Percent of Total Billed Charges,47% of Total Billed Charges,106.2,90,,13.144,Percent of Total Billed Charges,90% of Total Billed Charges,69.33,58.75,,57.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.46,47,,46.248,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,55.46,47,,46.248,Percent of Total Billed Charges,47% of Total Billed Charges,2000,100,,,Case Rate,Pays based on per visit rate,55.46,47,,32.304,Percent of Total Billed Charges,47% of Total Billed Charges,55.46,47,,32.304,Percent of Total Billed Charges,47% of Total Billed Charges,55.46,2000,
THORACENTESIS PF,1500197,CDM,450,RC,,,Outpatient,,,353.00,353.00,,207.39,58.75,,112.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,207.39,58.75,,112.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,170.89,48.41,,92.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,317.7,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,317.7,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,165.91,47,,89.864,Percent of Total Billed Charges,47% of Total Billed Charges,317.7,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,207.39,58.75,,112.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,165.91,47,,89.864,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,165.91,47,,89.864,Percent of Total Billed Charges,47% of Total Billed Charges,2000,100,,,Case Rate,Pays based on per visit rate,165.91,47,,5.92,Percent of Total Billed Charges,47% of Total Billed Charges,165.91,47,,5.92,Percent of Total Billed Charges,47% of Total Billed Charges,165.91,2000,
THORACENTESIS/TB INC,1500198,CDM,450,RC,,,Outpatient,,,180.00,180.00,,105.75,58.75,,81.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,105.75,58.75,,81.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,87.14,48.41,,67.384,Percent of Total Billed Charges,48.41% of Total Billed Charges,162,90,,41.976,Percent of Total Billed Charges,90% of Total Billed Charges,162,90,,41.976,Percent of Total Billed Charges,90% of Total Billed Charges,84.6,47,,65.424,Percent of Total Billed Charges,47% of Total Billed Charges,162,90,,41.976,Percent of Total Billed Charges,90% of Total Billed Charges,105.75,58.75,,81.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,84.6,47,,65.424,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,84.6,47,,65.424,Percent of Total Billed Charges,47% of Total Billed Charges,2000,100,,,Case Rate,Pays based on per visit rate,84.6,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,84.6,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,84.6,2000,
FB REM SIMPLE KNEE,1500202,CDM,270,RC,,,Outpatient,,,123.00,123.00,,72.26,58.75,,103.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,72.26,58.75,,103.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,59.54,48.41,,85.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,110.7,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,110.7,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,57.81,47,,82.72,Percent of Total Billed Charges,47% of Total Billed Charges,110.7,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,72.26,58.75,,103.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,57.81,47,,82.72,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,57.81,47,,82.72,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,57.81,47,,5.376,Percent of Total Billed Charges,47% of Total Billed Charges,57.81,47,,5.376,Percent of Total Billed Charges,47% of Total Billed Charges,57.81,110.7,
FB REM EAR W/O ANES,1500205,CDM,450,RC,69200,HCPCS,Outpatient,,,239.00,239.00,,140.41,58.75,,84.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,140.41,58.75,,84.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,115.7,48.41,,69.576,Percent of Total Billed Charges,48.41% of Total Billed Charges,119.84,100,,7.848,fee Schedule,100% of ASC Tier Groupings ,119.84,100,,7.848,Fee Schedule,100% of ASC Tier Groupings,112.33,47,,67.552,Percent of Total Billed Charges,47% of Total Billed Charges,119.84,100,,7.848,Fee Schedule,100% of ASC Tier Groupings,140.41,58.75,,84.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,112.33,47,,67.552,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,112.33,47,,67.552,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.54,115,,25.568,Fee Schedule,115% of CMS OPPS Rate,48.54,115,,25.568,Fee Schedule,115% of CMS OPPS Rate,48.54,140.41,
REDTN TOES NO ANES,1500207,CDM,450,RC,28630,HCPCS,Outpatient,,,174.00,174.00,,102.23,58.75,,101.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,102.23,58.75,,101.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.23,48.41,,83.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,236.32,100,,16.552,fee Schedule,100% of ASC Tier Groupings ,236.32,100,,16.552,Fee Schedule,100% of ASC Tier Groupings,81.78,47,,81.216,Percent of Total Billed Charges,47% of Total Billed Charges,236.32,100,,16.552,Fee Schedule,100% of ASC Tier Groupings,102.23,58.75,,101.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.64,100,,,Fee Schedule,100% of ASC Tier Groupings,81.78,47,,81.216,Percent of Total Billed Charges,47% of Total Billed charges,69.64,100,,,Fee Schedule,100% ASC Tier Groupings,81.78,47,,81.216,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,114.44,115,,6.016,Fee Schedule,115% of CMS OPPS Rate,114.44,115,,6.016,Fee Schedule,115% of CMS OPPS Rate,69.64,236.32,
TREATMENT ROOM,1500209,CDM,761,RC,99211,HCPCS,Outpatient,,,220.00,220.00,,129.25,58.75,,139.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,129.25,58.75,,139.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,106.5,48.41,,115.024,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.49,100,,24.232,fee Schedule,100% of BCBS fee schedule,22.49,100,,24.232,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,103.4,47,,111.672,Percent of Total Billed Charges,47% of Total Billed Charges,22.49,100,,24.232,Fee Schedule,100% of BCBS PPO fee schedule,129.25,58.75,,139.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,103.4,47,,111.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,103.4,47,,111.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.12,115,,11.656,Fee Schedule,115% of CMS OPPS Rate,9.12,115,,11.656,Fee Schedule,115% of CMS OPPS Rate,9.12,129.25,
I&D PERIRECTAL ABCES,1500212,CDM,450,RC,46050,HCPCS,Outpatient,,,179.65,179.65,,105.54,58.75,,101.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,105.54,58.75,,101.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.97,48.41,,83.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,835.52,100,,21.6,fee Schedule,100% of ASC Tier Groupings ,835.52,100,,21.6,Fee Schedule,100% of ASC Tier Groupings,84.44,47,,81.216,Percent of Total Billed Charges,47% of Total Billed Charges,835.52,100,,21.6,Fee Schedule,100% of ASC Tier Groupings,105.54,58.75,,101.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,334.06,100,,,Fee Schedule,100% of ASC Tier Groupings,84.44,47,,81.216,Percent of Total Billed Charges,47% of Total Billed charges,334.06,100,,,Fee Schedule,100% ASC Tier Groupings,84.44,47,,81.216,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,102.57,115,,8.48,Fee Schedule,115% of CMS OPPS Rate,102.57,115,,8.48,Fee Schedule,115% of CMS OPPS Rate,84.44,835.52,
IV INF HYDRA ADDL HR,1500214,CDM,260,RC,96361,HCPCS,Outpatient,,,216.00,216.00,,126.9,58.75,,101.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,126.9,58.75,,101.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,104.57,48.41,,83.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,36.59,100,,18.216,fee Schedule,100% of BCBS fee schedule,36.59,100,,18.216,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,101.52,47,,81.216,Percent of Total Billed Charges,47% of Total Billed Charges,36.59,100,,18.216,Fee Schedule,100% of BCBS PPO fee schedule,126.9,58.75,,101.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,101.52,47,,81.216,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,101.52,47,,81.216,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,11.86,115,,25.024,Fee Schedule,115% of CMS OPPS Rate,11.86,115,,25.024,Fee Schedule,115% of CMS OPPS Rate,11.86,150,
IV INF DRUG INITIAL,1500215,CDM,260,RC,96365,HCPCS,Outpatient,,,297.00,297.00,,174.49,58.75,,101.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,174.49,58.75,,101.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,143.78,48.41,,83.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,176.4,100,,5.76,fee Schedule,100% of BCBS fee schedule,176.4,100,,5.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,139.59,47,,81.216,Percent of Total Billed Charges,47% of Total Billed Charges,176.4,100,,5.76,Fee Schedule,100% of BCBS PPO fee schedule,174.49,58.75,,101.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,139.59,47,,81.216,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,139.59,47,,81.216,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,57.85,115,,12.784,Fee Schedule,115% of CMS OPPS Rate,57.85,115,,12.784,Fee Schedule,115% of CMS OPPS Rate,57.85,176.4,
IV INF DRUG EA AD HR,1500216,CDM,260,RC,96366,HCPCS,Outpatient,,,216.00,216.00,,126.9,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,126.9,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,104.57,48.41,,30.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,36.59,100,,10.296,fee Schedule,100% of BCBS fee schedule,36.59,100,,10.296,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,101.52,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,36.59,100,,10.296,Fee Schedule,100% of BCBS PPO fee schedule,126.9,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,101.52,47,,29.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,101.52,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,20,115,,7.032,Fee Schedule,115% of CMS OPPS Rate,20,115,,7.032,Fee Schedule,115% of CMS OPPS Rate,20,150,
IV INF SEQTL UPTO HR,1500217,CDM,260,RC,96367,HCPCS,Outpatient,,,216.00,216.00,,126.9,58.75,,215.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,126.9,58.75,,215.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,104.57,48.41,,177.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,58.05,100,,4.32,fee Schedule,100% of BCBS fee schedule,58.05,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,101.52,47,,172.544,Percent of Total Billed Charges,47% of Total Billed Charges,58.05,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,126.9,58.75,,215.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,101.52,47,,172.544,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,101.52,47,,172.544,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,27.09,115,,2.592,Fee Schedule,115% of CMS OPPS Rate,27.09,115,,2.592,Fee Schedule,115% of CMS OPPS Rate,27.09,150,
IV PUSH SEQ SAME DRG,1500218,CDM,260,RC,96376,HCPCS,Outpatient,,,216.00,216.00,,126.9,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,126.9,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,104.57,48.41,,116.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,32.55,100,,21.6,fee Schedule,100% of BCBS fee schedule,32.55,100,,21.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,101.52,47,,112.8,Percent of Total Billed Charges,47% of Total Billed Charges,32.55,100,,21.6,Fee Schedule,100% of BCBS PPO fee schedule,126.9,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,101.52,47,,112.8,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,101.52,47,,112.8,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,101.52,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,101.52,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,32.55,150,
SYNOVIAL ASPIRATION,1500219,CDM,450,RC,20610,HCPCS,Outpatient,,,79.00,79.00,,46.41,58.75,,62.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.41,58.75,,62.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.24,48.41,,51.12,Percent of Total Billed Charges,48.41% of Total Billed Charges,286.72,100,,84.24,fee Schedule,100% of ASC Tier Groupings ,286.72,100,,84.24,Fee Schedule,100% of ASC Tier Groupings,37.13,47,,49.632,Percent of Total Billed Charges,47% of Total Billed Charges,286.72,100,,84.24,Fee Schedule,100% of ASC Tier Groupings,46.41,58.75,,62.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.57,100,,,Fee Schedule,100% of ASC Tier Groupings,37.13,47,,49.632,Percent of Total Billed Charges,47% of Total Billed charges,27.57,100,,,Fee Schedule,100% ASC Tier Groupings,37.13,47,,49.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.97,115,,7.896,Fee Schedule,115% of CMS OPPS Rate,45.97,115,,7.896,Fee Schedule,115% of CMS OPPS Rate,27.57,286.72,
CLSD REF ELBOW W/0 A,1500221,CDM,450,RC,24600,HCPCS,Outpatient,,,458.90,458.90,,269.6,58.75,,63.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,269.6,58.75,,63.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,222.15,48.41,,52.416,Percent of Total Billed Charges,48.41% of Total Billed Charges,236.32,100,,46.8,fee Schedule,100% of ASC Tier Groupings ,236.32,100,,46.8,Fee Schedule,100% of ASC Tier Groupings,215.68,47,,50.888,Percent of Total Billed Charges,47% of Total Billed Charges,236.32,100,,46.8,Fee Schedule,100% of ASC Tier Groupings,269.6,58.75,,63.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.76,100,,,Fee Schedule,100% of ASC Tier Groupings,215.68,47,,50.888,Percent of Total Billed Charges,47% of Total Billed charges,86.76,100,,,Fee Schedule,100% ASC Tier Groupings,215.68,47,,50.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,356.29,115,,7.768,Fee Schedule,115% of CMS OPPS Rate,356.29,115,,7.768,Fee Schedule,115% of CMS OPPS Rate,86.76,356.29,
INT OBS CARE MOD PF,1500223,CDM,982,RC,99219,HCPCS,Outpatient,,,246.00,246.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
INT OBS CARE HIGH PF,1500224,CDM,982,RC,99220,HCPCS,Outpatient,,,305.00,305.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
OBS CARE DISCH MT PF,1500225,CDM,982,RC,99217,HCPCS,Outpatient,,,118.85,118.85,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
OBS ADM/DIS SM DY PF,1500226,CDM,982,RC,99235,HCPCS,Outpatient,,,237.00,237.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
DRAIN FING ABS SIMPL,1500227,CDM,450,RC,26010,HCPCS,Outpatient,,,300.00,300.00,,176.25,58.75,,304.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,176.25,58.75,,304.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.23,48.41,,250.664,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,48.96,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,48.96,Fee Schedule,100% of ASC Tier Groupings,141,47,,243.368,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,48.96,Fee Schedule,100% of ASC Tier Groupings,176.25,58.75,,304.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.6,100,,,Fee Schedule,100% of ASC Tier Groupings,141,47,,243.368,Percent of Total Billed Charges,47% of Total Billed charges,75.6,100,,,Fee Schedule,100% ASC Tier Groupings,141,47,,243.368,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,142.59,115,,48.88,Fee Schedule,115% of CMS OPPS Rate,142.59,115,,48.88,Fee Schedule,115% of CMS OPPS Rate,75.6,191.52,
INT OBS LOW PF,1500229,CDM,982,RC,99218,HCPCS,Outpatient,,,190.00,190.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
FB REMOV SC (ER),1500230,CDM,450,RC,10120,HCPCS,Outpatient,,,132.00,132.00,,77.55,58.75,,68.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,77.55,58.75,,68.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,63.9,48.41,,56.544,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,22.32,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,22.32,Fee Schedule,100% of ASC Tier Groupings,62.04,47,,54.896,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,22.32,Fee Schedule,100% of ASC Tier Groupings,77.55,58.75,,68.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,85.2,100,,,Fee Schedule,100% of ASC Tier Groupings,62.04,47,,54.896,Percent of Total Billed Charges,47% of Total Billed charges,85.2,100,,,Fee Schedule,100% ASC Tier Groupings,62.04,47,,54.896,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,106.81,115,,6.56,Fee Schedule,115% of CMS OPPS Rate,106.81,115,,6.56,Fee Schedule,115% of CMS OPPS Rate,62.04,349.44,
PUN ASP ABC (ER),1500232,CDM,450,RC,10160,HCPCS,Outpatient,,,135.35,135.35,,79.52,58.75,,297.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.52,58.75,,297.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,65.52,48.41,,244.992,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,16.24,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,16.24,Fee Schedule,100% of ASC Tier Groupings,63.61,47,,237.856,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,16.24,Fee Schedule,100% of ASC Tier Groupings,79.52,58.75,,297.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.9,100,,,Fee Schedule,100% of ASC Tier Groupings,63.61,47,,237.856,Percent of Total Billed Charges,47% of Total Billed charges,66.9,100,,,Fee Schedule,100% ASC Tier Groupings,63.61,47,,237.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,98.2,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,98.2,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,63.61,349.44,
COMP REP<5CM ADD(ER),1500234,CDM,450,RC,13122,HCPCS,Outpatient,,,124.80,124.80,,73.32,58.75,,91.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.32,58.75,,91.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,60.42,48.41,,75.464,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,58.66,47,,73.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,73.32,58.75,,91.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,58.66,47,,73.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,58.66,47,,73.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,83.2,115,,50.536,Fee Schedule,115% of CMS OPPS Rate,83.2,115,,50.536,Fee Schedule,115% of CMS OPPS Rate,58.66,83.2,
"FB REMOVE, F/ARM(ER)",1500238,CDM,450,RC,25248,HCPCS,Outpatient,,,608.32,608.32,,357.39,58.75,,66.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,357.39,58.75,,66.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,294.49,48.41,,54.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,1481.76,100,,24.48,fee Schedule,100% of ASC Tier Groupings ,1481.76,100,,24.48,Fee Schedule,100% of ASC Tier Groupings,285.91,47,,53.28,Percent of Total Billed Charges,47% of Total Billed Charges,1481.76,100,,24.48,Fee Schedule,100% of ASC Tier Groupings,357.39,58.75,,66.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,603.08,100,,,Fee Schedule,100% of ASC Tier Groupings,285.91,47,,53.28,Percent of Total Billed Charges,47% of Total Billed charges,603.08,100,,,Fee Schedule,100% ASC Tier Groupings,285.91,47,,53.28,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,426.59,115,,44.56,Fee Schedule,115% of CMS OPPS Rate,426.59,115,,44.56,Fee Schedule,115% of CMS OPPS Rate,285.91,1481.76,
ANT NASAL PK (ER),1500240,CDM,450,RC,30901,HCPCS,Outpatient,,,83.65,83.65,,49.14,58.75,,113.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.14,58.75,,113.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.49,48.41,,93.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,119.84,100,,13.464,fee Schedule,100% of ASC Tier Groupings ,119.84,100,,13.464,Fee Schedule,100% of ASC Tier Groupings,39.32,47,,90.616,Percent of Total Billed Charges,47% of Total Billed Charges,119.84,100,,13.464,Fee Schedule,100% of ASC Tier Groupings,49.14,58.75,,113.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,39.32,47,,90.616,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,39.32,47,,90.616,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,57.5,115,,7.144,Fee Schedule,115% of CMS OPPS Rate,57.5,115,,7.144,Fee Schedule,115% of CMS OPPS Rate,39.32,119.84,
I & D NASAL,1500242,CDM,450,RC,30000,HCPCS,Outpatient,,,172.80,172.80,,101.52,58.75,,51.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,101.52,58.75,,51.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,83.65,48.41,,42.496,Percent of Total Billed Charges,48.41% of Total Billed Charges,222.88,100,,4.968,fee Schedule,100% of ASC Tier Groupings ,222.88,100,,4.968,Fee Schedule,100% of ASC Tier Groupings,81.22,47,,41.256,Percent of Total Billed Charges,47% of Total Billed Charges,222.88,100,,4.968,Fee Schedule,100% of ASC Tier Groupings,101.52,58.75,,51.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.05,100,,,Fee Schedule,100% of ASC Tier Groupings,81.22,47,,41.256,Percent of Total Billed Charges,47% of Total Billed charges,89.05,100,,,Fee Schedule,100% ASC Tier Groupings,81.22,47,,41.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,123.59,115,,137.24,Fee Schedule,115% of CMS OPPS Rate,123.59,115,,137.24,Fee Schedule,115% of CMS OPPS Rate,81.22,222.88,
CL RED DIS/AN/ANE ER,1500244,CDM,450,RC,27842,HCPCS,Outpatient,,,647.25,647.25,,380.26,58.75,,87.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,380.26,58.75,,87.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,313.33,48.41,,72.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,1481.76,100,,2.16,fee Schedule,100% of ASC Tier Groupings ,1481.76,100,,2.16,Fee Schedule,100% of ASC Tier Groupings,304.21,47,,70.032,Percent of Total Billed Charges,47% of Total Billed Charges,1481.76,100,,2.16,Fee Schedule,100% of ASC Tier Groupings,380.26,58.75,,87.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,798.9,100,,,Fee Schedule,100% of ASC Tier Groupings,304.21,47,,70.032,Percent of Total Billed Charges,47% of Total Billed charges,798.9,100,,,Fee Schedule,100% ASC Tier Groupings,304.21,47,,70.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,504.95,115,,19.744,Fee Schedule,115% of CMS OPPS Rate,504.95,115,,19.744,Fee Schedule,115% of CMS OPPS Rate,304.21,1481.76,
CHEST TUBE PLACEMENT,1500246,CDM,450,RC,32551,HCPCS,Outpatient,,,2786.00,2786.00,,1636.78,58.75,,160.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,1636.78,58.75,,160.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,1348.7,48.41,,132.064,Percent of Total Billed Charges,48.41% of Total Billed Charges,1783.04,100,,15.12,fee Schedule,100% of ASC Tier Groupings ,1783.04,100,,15.12,Fee Schedule,100% of ASC Tier Groupings,1309.42,47,,128.216,Percent of Total Billed Charges,47% of Total Billed Charges,1783.04,100,,15.12,Fee Schedule,100% of ASC Tier Groupings,1636.78,58.75,,160.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,445.29,100,,,Fee Schedule,100% of ASC Tier Groupings,1309.42,47,,128.216,Percent of Total Billed Charges,47% of Total Billed charges,445.29,100,,,Fee Schedule,100% ASC Tier Groupings,1309.42,47,,128.216,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,156.56,115,,31.432,Fee Schedule,115% of CMS OPPS Rate,156.56,115,,31.432,Fee Schedule,115% of CMS OPPS Rate,156.56,1783.04,
FB REM SIMPLE SKIN,1500248,CDM,450,RC,10120,HCPCS,Outpatient,,,146.00,146.00,,85.78,58.75,,28.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,85.78,58.75,,28.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,70.68,48.41,,23.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,14.872,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,14.872,Fee Schedule,100% of ASC Tier Groupings,68.62,47,,22.88,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,14.872,Fee Schedule,100% of ASC Tier Groupings,85.78,58.75,,28.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,85.2,100,,,Fee Schedule,100% of ASC Tier Groupings,68.62,47,,22.88,Percent of Total Billed Charges,47% of Total Billed charges,85.2,100,,,Fee Schedule,100% ASC Tier Groupings,68.62,47,,22.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,106.81,115,,3.76,Fee Schedule,115% of CMS OPPS Rate,106.81,115,,3.76,Fee Schedule,115% of CMS OPPS Rate,68.62,349.44,
I&D VAG ABCESS,1500249,CDM,450,RC,57010,HCPCS,Outpatient,,,632.60,632.60,,371.65,58.75,,94.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,371.65,58.75,,94.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,306.24,48.41,,77.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,2730.56,100,,1.44,fee Schedule,100% of ASC Tier Groupings ,2730.56,100,,1.44,Fee Schedule,100% of ASC Tier Groupings,297.32,47,,75.48,Percent of Total Billed Charges,47% of Total Billed Charges,2730.56,100,,1.44,Fee Schedule,100% of ASC Tier Groupings,371.65,58.75,,94.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,1081.52,100,,,Fee Schedule,100% of ASC Tier Groupings,297.32,47,,75.48,Percent of Total Billed Charges,47% of Total Billed charges,1081.52,100,,,Fee Schedule,100% ASC Tier Groupings,297.32,47,,75.48,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,462.77,115,,29.704,Fee Schedule,115% of CMS OPPS Rate,462.77,115,,29.704,Fee Schedule,115% of CMS OPPS Rate,297.32,2730.56,
FB REMOVAL FOOT,1500251,CDM,450,RC,28190,HCPCS,Outpatient,,,194.85,194.85,,114.47,58.75,,188.896,Percent of Total Billed Charges,58.75% of Total Billed Charges,114.47,58.75,,188.896,Percent of Total Billed Charges,58.75% of Total Billed Charges,94.33,48.41,,155.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,667.52,100,,3.712,fee Schedule,100% of ASC Tier Groupings ,667.52,100,,3.712,Fee Schedule,100% of ASC Tier Groupings,91.58,47,,151.112,Percent of Total Billed Charges,47% of Total Billed Charges,667.52,100,,3.712,Fee Schedule,100% of ASC Tier Groupings,114.47,58.75,,188.896,Percent of Total Billed Charges,58.75% of Total Billed Charges,137.08,100,,,Fee Schedule,100% of ASC Tier Groupings,91.58,47,,151.112,Percent of Total Billed Charges,47% of Total Billed charges,137.08,100,,,Fee Schedule,100% ASC Tier Groupings,91.58,47,,151.112,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,136.52,115,,14.288,Fee Schedule,115% of CMS OPPS Rate,136.52,115,,14.288,Fee Schedule,115% of CMS OPPS Rate,91.58,667.52,
I&D PILONIDAL CYT SI,1500253,CDM,450,RC,10080,HCPCS,Outpatient,,,141.70,141.70,,83.25,58.75,,8.696,Percent of Total Billed Charges,58.75% of Total Billed Charges,83.25,58.75,,8.696,Percent of Total Billed Charges,58.75% of Total Billed Charges,68.6,48.41,,7.168,Percent of Total Billed Charges,48.41% of Total Billed Charges,667.52,100,,7.776,fee Schedule,100% of ASC Tier Groupings ,667.52,100,,7.776,Fee Schedule,100% of ASC Tier Groupings,66.6,47,,6.96,Percent of Total Billed Charges,47% of Total Billed Charges,667.52,100,,7.776,Fee Schedule,100% of ASC Tier Groupings,83.25,58.75,,8.696,Percent of Total Billed Charges,58.75% of Total Billed Charges,171.76,100,,,Fee Schedule,100% of ASC Tier Groupings,66.6,47,,6.96,Percent of Total Billed Charges,47% of Total Billed charges,171.76,100,,,Fee Schedule,100% ASC Tier Groupings,66.6,47,,6.96,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,105.86,115,,19.176,Fee Schedule,115% of CMS OPPS Rate,105.86,115,,19.176,Fee Schedule,115% of CMS OPPS Rate,66.6,667.52,
I&D PILONIDAL CYT CO,1500255,CDM,450,RC,10081,HCPCS,Outpatient,,,241.00,241.00,,141.59,58.75,,24.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,141.59,58.75,,24.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,116.67,48.41,,20.024,Percent of Total Billed Charges,48.41% of Total Billed Charges,667.52,100,,11.448,fee Schedule,100% of ASC Tier Groupings ,667.52,100,,11.448,Fee Schedule,100% of ASC Tier Groupings,113.27,47,,19.44,Percent of Total Billed Charges,47% of Total Billed Charges,667.52,100,,11.448,Fee Schedule,100% of ASC Tier Groupings,141.59,58.75,,24.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,206.44,100,,,Fee Schedule,100% of ASC Tier Groupings,113.27,47,,19.44,Percent of Total Billed Charges,47% of Total Billed charges,206.44,100,,,Fee Schedule,100% ASC Tier Groupings,113.27,47,,19.44,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,172.36,115,,4.136,Fee Schedule,115% of CMS OPPS Rate,172.36,115,,4.136,Fee Schedule,115% of CMS OPPS Rate,113.27,667.52,
EXCISION OF NAILFOLD,1500257,CDM,450,RC,11765,HCPCS,Outpatient,,,109.73,109.73,,64.47,58.75,,88.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.47,58.75,,88.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,53.12,48.41,,72.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,93.6,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,93.6,Fee Schedule,100% of ASC Tier Groupings,51.57,47,,70.688,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,93.6,Fee Schedule,100% of ASC Tier Groupings,64.47,58.75,,88.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,51.57,47,,70.688,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,51.57,47,,70.688,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,95.29,115,,5.376,Fee Schedule,115% of CMS OPPS Rate,95.29,115,,5.376,Fee Schedule,115% of CMS OPPS Rate,51.57,349.44,
EXCISION OF LIP,1500259,CDM,450,RC,11441,HCPCS,Outpatient,,,186.26,186.26,,109.43,58.75,,37.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,109.43,58.75,,37.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,90.17,48.41,,30.848,Percent of Total Billed Charges,48.41% of Total Billed Charges,667.52,100,,1.44,fee Schedule,100% of ASC Tier Groupings ,667.52,100,,1.44,Fee Schedule,100% of ASC Tier Groupings,87.54,47,,29.952,Percent of Total Billed Charges,47% of Total Billed Charges,667.52,100,,1.44,Fee Schedule,100% of ASC Tier Groupings,109.43,58.75,,37.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,94.76,100,,,Fee Schedule,100% of ASC Tier Groupings,87.54,47,,29.952,Percent of Total Billed Charges,47% of Total Billed charges,94.76,100,,,Fee Schedule,100% ASC Tier Groupings,87.54,47,,29.952,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,134.92,115,,23.312,Fee Schedule,115% of CMS OPPS Rate,134.92,115,,23.312,Fee Schedule,115% of CMS OPPS Rate,87.54,667.52,
EXC EPIDERMOID I CYS,1500261,CDM,361,RC,11406,HCPCS,Outpatient,,,341.00,341.00,,200.34,58.75,,48.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,200.34,58.75,,48.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,165.08,48.41,,39.6,Percent of Total Billed Charges,48.41% of Total Billed Charges,1500.8,100,,12.568,fee Schedule,100% of ASC Tier Groupings ,1500.8,100,,12.568,Fee Schedule,100% of ASC Tier Groupings,160.27,47,,38.448,Percent of Total Billed Charges,47% of Total Billed Charges,1500.8,100,,12.568,Fee Schedule,100% of ASC Tier Groupings,200.34,58.75,,48.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,494.68,100,,,Fee Schedule,100% of ASC Tier Groupings,160.27,47,,38.448,Percent of Total Billed Charges,47% of Total Billed charges,494.68,100,,,Fee Schedule,100% ASC Tier Groupings,160.27,47,,38.448,Percent of Total Billed Charges,47% of Total Billed Charges,620,100,,,Fee Schedule,100% of ASC Tier Groupings,251.71,115,,19.176,Fee Schedule,115% of CMS OPPS Rate,251.71,115,,19.176,Fee Schedule,115% of CMS OPPS Rate,160.27,1500.8,
TRIGGERING >3 MUSCLE,1500263,CDM,450,RC,20553,HCPCS,Outpatient,,,60.85,60.85,,35.75,58.75,,226.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.75,58.75,,226.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.46,48.41,,186.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,286.72,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,286.72,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,28.6,47,,181.216,Percent of Total Billed Charges,47% of Total Billed Charges,286.72,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,35.75,58.75,,226.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,26.76,100,,,Fee Schedule,100% of ASC Tier Groupings,28.6,47,,181.216,Percent of Total Billed Charges,47% of Total Billed charges,26.76,100,,,Fee Schedule,100% ASC Tier Groupings,28.6,47,,181.216,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,42.55,115,,4.136,Fee Schedule,115% of CMS OPPS Rate,42.55,115,,4.136,Fee Schedule,115% of CMS OPPS Rate,26.76,286.72,
CENT LINE PLACEMENT,1500265,CDM,450,RC,36556,HCPCS,Outpatient,,,200.75,200.75,,117.94,58.75,,258.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,117.94,58.75,,258.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,97.18,48.41,,213.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,1783.04,100,,96.768,fee Schedule,100% of ASC Tier Groupings ,1783.04,100,,96.768,Fee Schedule,100% of ASC Tier Groupings,94.35,47,,207.192,Percent of Total Billed Charges,47% of Total Billed Charges,1783.04,100,,96.768,Fee Schedule,100% of ASC Tier Groupings,117.94,58.75,,258.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,1137.15,100,,,Fee Schedule,100% of ASC Tier Groupings,94.35,47,,207.192,Percent of Total Billed Charges,47% of Total Billed charges,1137.15,100,,,Fee Schedule,100% ASC Tier Groupings,94.35,47,,207.192,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,85.96,115,,47.376,Fee Schedule,115% of CMS OPPS Rate,85.96,115,,47.376,Fee Schedule,115% of CMS OPPS Rate,85.96,1783.04,
CMPLX RPR <2.5CM OTC,1500267,CDM,450,RC,13131,HCPCS,Outpatient,,,401.90,401.90,,236.12,58.75,,21.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,236.12,58.75,,21.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,194.56,48.41,,17.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,85.336,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,85.336,Fee Schedule,100% of ASC Tier Groupings,188.89,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,85.336,Fee Schedule,100% of ASC Tier Groupings,236.12,58.75,,21.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,188.89,47,,16.92,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,188.89,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,246.2,115,,34.12,Fee Schedule,115% of CMS OPPS Rate,246.2,115,,34.12,Fee Schedule,115% of CMS OPPS Rate,145.5,349.44,
ADM OF H1N1,1500269,CDM,771,RC,G9141,HCPCS,Outpatient,,,18.50,18.50,,10.87,58.75,,63.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.87,58.75,,63.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.96,48.41,,51.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.65,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,16.65,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.7,47,,50.448,Percent of Total Billed Charges,47% of Total Billed Charges,16.65,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,10.87,58.75,,63.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.7,47,,50.448,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.7,47,,50.448,Percent of Total Billed Charges,47% of Total Billed Charges,30,100,,,Case Rate,Pays based on per visit rate,8.7,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,8.7,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,8.7,30,
OMT 3-4 REGION,1500270,CDM,450,RC,98926,HCPCS,Outpatient,,,51.70,51.70,,30.37,58.75,,223.696,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.37,58.75,,223.696,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.03,48.41,,184.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,23.54,100,,262.8,fee Schedule,100% of BCBS fee schedule,23.54,100,,262.8,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,24.3,47,,178.96,Percent of Total Billed Charges,47% of Total Billed Charges,23.54,100,,262.8,Fee Schedule,100% of BCBS PPO fee schedule,30.37,58.75,,223.696,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.3,47,,178.96,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,24.3,47,,178.96,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,36.13,115,,6.392,Fee Schedule,115% of CMS OPPS Rate,36.13,115,,6.392,Fee Schedule,115% of CMS OPPS Rate,23.54,36.13,
I&D BUC ABCESS,1500272,CDM,450,RC,40800,HCPCS,Outpatient,,,188.00,188.00,,110.45,58.75,,70.48,Percent of Total Billed Charges,58.75% of Total Billed Charges,110.45,58.75,,70.48,Percent of Total Billed Charges,58.75% of Total Billed Charges,91.01,48.41,,58.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,667.52,100,,37.8,fee Schedule,100% of ASC Tier Groupings ,667.52,100,,37.8,Fee Schedule,100% of ASC Tier Groupings,88.36,47,,56.384,Percent of Total Billed Charges,47% of Total Billed Charges,667.52,100,,37.8,Fee Schedule,100% of ASC Tier Groupings,110.45,58.75,,70.48,Percent of Total Billed Charges,58.75% of Total Billed Charges,129.98,100,,,Fee Schedule,100% of ASC Tier Groupings,88.36,47,,56.384,Percent of Total Billed Charges,47% of Total Billed charges,129.98,100,,,Fee Schedule,100% ASC Tier Groupings,88.36,47,,56.384,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,121.51,115,,23.312,Fee Schedule,115% of CMS OPPS Rate,121.51,115,,23.312,Fee Schedule,115% of CMS OPPS Rate,88.36,667.52,
SIM REP SCP NCKTRUK,1500274,CDM,450,RC,12001,HCPCS,Outpatient,,,79.65,79.65,,46.79,58.75,,63.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.79,58.75,,63.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.56,48.41,,52.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,60.192,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,60.192,Fee Schedule,100% of ASC Tier Groupings,37.44,47,,50.8,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,60.192,Fee Schedule,100% of ASC Tier Groupings,46.79,58.75,,63.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.44,47,,50.8,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,37.44,47,,50.8,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.21,115,,4.888,Fee Schedule,115% of CMS OPPS Rate,45.21,115,,4.888,Fee Schedule,115% of CMS OPPS Rate,37.44,191.52,
SIM RP SP NK TNK 2.6,1500276,CDM,450,RC,12002,HCPCS,Outpatient,,,102.25,102.25,,60.07,58.75,,46.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,60.07,58.75,,46.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.5,48.41,,38.416,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,7.2,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,7.2,Fee Schedule,100% of ASC Tier Groupings,48.06,47,,37.296,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,7.2,Fee Schedule,100% of ASC Tier Groupings,60.07,58.75,,46.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.06,47,,37.296,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,48.06,47,,37.296,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,59.43,115,,14.288,Fee Schedule,115% of CMS OPPS Rate,59.43,115,,14.288,Fee Schedule,115% of CMS OPPS Rate,48.06,191.52,
CL TREAT KNEE DISL,1500278,CDM,450,RC,27560,HCPCS,Outpatient,,,481.95,481.95,LT,283.15,58.75,,18.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,283.15,58.75,,18.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,233.31,48.41,,15.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,236.32,100,,56.88,fee Schedule,100% of ASC Tier Groupings ,236.32,100,,56.88,Fee Schedule,100% of ASC Tier Groupings,226.52,47,,14.888,Percent of Total Billed Charges,47% of Total Billed Charges,236.32,100,,56.88,Fee Schedule,100% of ASC Tier Groupings,283.15,58.75,,18.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.76,100,,,Fee Schedule,100% of ASC Tier Groupings,226.52,47,,14.888,Percent of Total Billed Charges,47% of Total Billed charges,86.76,100,,,Fee Schedule,100% ASC Tier Groupings,226.52,47,,14.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,352.96,115,,40.232,Fee Schedule,115% of CMS OPPS Rate,352.96,115,,40.232,Fee Schedule,115% of CMS OPPS Rate,86.76,352.96,
CL SHD RED W FRACTUR,1500280,CDM,450,RC,23665,HCPCS,Outpatient,,,551.05,551.05,,323.74,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,323.74,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,266.76,48.41,,37.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,1481.76,100,,27.36,fee Schedule,100% of ASC Tier Groupings ,1481.76,100,,27.36,Fee Schedule,100% of ASC Tier Groupings,258.99,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,1481.76,100,,27.36,Fee Schedule,100% of ASC Tier Groupings,323.74,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,603.08,100,,,Fee Schedule,100% of ASC Tier Groupings,258.99,47,,36.848,Percent of Total Billed Charges,47% of Total Billed charges,603.08,100,,,Fee Schedule,100% ASC Tier Groupings,258.99,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,413.98,115,,4.512,Fee Schedule,115% of CMS OPPS Rate,413.98,115,,4.512,Fee Schedule,115% of CMS OPPS Rate,258.99,1481.76,
INJ/ASP ELBOW ANK WR,1500283,CDM,450,RC,20605,HCPCS,Outpatient,,,45.00,45.00,,26.44,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,26.44,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.78,48.41,,6.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,286.72,100,,36.72,fee Schedule,100% of ASC Tier Groupings ,286.72,100,,36.72,Fee Schedule,100% of ASC Tier Groupings,21.15,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,286.72,100,,36.72,Fee Schedule,100% of ASC Tier Groupings,26.44,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.21,100,,,Fee Schedule,100% of ASC Tier Groupings,21.15,47,,6.768,Percent of Total Billed Charges,47% of Total Billed charges,23.21,100,,,Fee Schedule,100% ASC Tier Groupings,21.15,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.71,115,,4.512,Fee Schedule,115% of CMS OPPS Rate,37.71,115,,4.512,Fee Schedule,115% of CMS OPPS Rate,21.15,286.72,
RP CMPX ADDL 5CM OR L,1500286,CDM,450,RC,13133,HCPCS,Outpatient,,,134.18,134.18,,78.83,58.75,,504.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,78.83,58.75,,504.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.96,48.41,,415.352,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,63.06,47,,403.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,78.83,58.75,,504.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,63.06,47,,403.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,63.06,47,,403.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,127.17,115,,4.512,Fee Schedule,115% of CMS OPPS Rate,127.17,115,,4.512,Fee Schedule,115% of CMS OPPS Rate,63.06,127.17,
RP CMPX 2.6 TO 7.5 CM,1500287,CDM,450,RC,13132,HCPCS,Outpatient,,,475.95,475.95,,279.62,58.75,,324.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,279.62,58.75,,324.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,230.41,48.41,,267.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,543.2,100,,60.624,fee Schedule,100% of ASC Tier Groupings ,543.2,100,,10.296,Fee Schedule,100% of ASC Tier Groupings,223.7,47,,259.256,Percent of Total Billed Charges,47% of Total Billed Charges,543.2,100,,10.296,Fee Schedule,100% of ASC Tier Groupings,279.62,58.75,,324.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,220.47,100,,,Fee Schedule,100% of ASC Tier Groupings,223.7,47,,259.256,Percent of Total Billed Charges,47% of Total Billed charges,220.47,100,,,Fee Schedule,100% ASC Tier Groupings,223.7,47,,259.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,307.73,115,,7.896,Fee Schedule,115% of CMS OPPS Rate,307.73,115,,7.896,Fee Schedule,115% of CMS OPPS Rate,220.47,543.2,
RE LESION EX DI .6-1,1500289,CDM,450,RC,11601,HCPCS,Outpatient,,,149.95,149.95,,88.1,58.75,,80.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,88.1,58.75,,80.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,72.59,48.41,,66.24,Percent of Total Billed Charges,48.41% of Total Billed Charges,667.52,100,,109.44,fee Schedule,100% of ASC Tier Groupings ,667.52,100,,44.64,Fee Schedule,100% of ASC Tier Groupings,70.48,47,,64.312,Percent of Total Billed Charges,47% of Total Billed Charges,667.52,100,,44.64,Fee Schedule,100% of ASC Tier Groupings,88.1,58.75,,80.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,122.62,100,,,Fee Schedule,100% of ASC Tier Groupings,70.48,47,,64.312,Percent of Total Billed Charges,47% of Total Billed charges,122.62,100,,,Fee Schedule,100% ASC Tier Groupings,70.48,47,,64.312,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,150.91,115,,48.88,Fee Schedule,115% of CMS OPPS Rate,150.91,115,,48.88,Fee Schedule,115% of CMS OPPS Rate,70.48,667.52,
EXCISION OF LESION 1.1-2 CM,1500292,CDM,450,RC,11422,HCPCS,Outpatient,,,135.10,135.10,,79.37,58.75,,29.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.37,58.75,,29.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,65.4,48.41,,24.376,Percent of Total Billed Charges,48.41% of Total Billed Charges,1500.8,100,,124.92,fee Schedule,100% of ASC Tier Groupings ,1500.8,100,,60.624,Fee Schedule,100% of ASC Tier Groupings,63.5,47,,23.672,Percent of Total Billed Charges,47% of Total Billed Charges,1500.8,100,,60.624,Fee Schedule,100% of ASC Tier Groupings,79.37,58.75,,29.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,94.49,100,,,Fee Schedule,100% of ASC Tier Groupings,63.5,47,,23.672,Percent of Total Billed Charges,47% of Total Billed charges,94.49,100,,,Fee Schedule,100% ASC Tier Groupings,63.5,47,,23.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,138.83,115,,6.92,Fee Schedule,115% of CMS OPPS Rate,138.83,115,,6.92,Fee Schedule,115% of CMS OPPS Rate,63.5,1500.8,
NERVE BLOCK INJECTION,1500295,CDM,450,RC,64400,HCPCS,Outpatient,,,99.20,99.20,,58.28,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.28,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.02,48.41,,9.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,286.72,100,,36.72,fee Schedule,100% of ASC Tier Groupings ,286.72,100,,109.44,Fee Schedule,100% of ASC Tier Groupings,46.62,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,286.72,100,,109.44,Fee Schedule,100% of ASC Tier Groupings,58.28,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.63,100,,,Fee Schedule,100% of ASC Tier Groupings,46.62,47,,9.4,Percent of Total Billed Charges,47% of Total Billed charges,66.63,100,,,Fee Schedule,100% ASC Tier Groupings,46.62,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,51.45,115,,4.704,Fee Schedule,115% of CMS OPPS Rate,51.45,115,,4.704,Fee Schedule,115% of CMS OPPS Rate,46.62,286.72,
TDAP INITIAL < 18 YEARS OLD,1500296,CDM,450,RC,90460,HCPCS,Outpatient,,,39.60,39.60,,23.27,58.75,,89.856,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.27,58.75,,89.856,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.17,48.41,,74.04,Percent of Total Billed Charges,48.41% of Total Billed Charges,35.64,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,35.64,90,,124.92,Percent of Total Billed Charges,90% of Total Billed Charges,18.61,47,,71.88,Percent of Total Billed Charges,47% of Total Billed Charges,35.64,90,,124.92,Percent of Total Billed Charges,90% of Total Billed Charges,23.27,58.75,,89.856,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.61,47,,71.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.61,47,,71.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.07,115,,175.968,Fee Schedule,115% of CMS OPPS Rate,23.07,115,,175.968,Fee Schedule,115% of CMS OPPS Rate,18.61,35.64,
TDAP INITIAL > 18 YEARS OLD,1500298,CDM,771,RC,90471,HCPCS,Outpatient,,,98.00,98.00,,57.58,58.75,,238.856,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.58,58.75,,238.856,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.44,48.41,,196.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,58.05,100,,0.008,fee Schedule,100% of BCBS fee schedule,58.05,100,,36.72,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,46.06,47,,191.08,Percent of Total Billed Charges,47% of Total Billed Charges,58.05,100,,36.72,Fee Schedule,100% of BCBS PPO fee schedule,57.58,58.75,,238.856,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.06,47,,191.08,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,46.06,47,,191.08,Percent of Total Billed Charges,47% of Total Billed Charges,30,100,,,Case Rate,Pays based on per visit rate,20.59,115,,86.48,Fee Schedule,115% of CMS OPPS Rate,20.59,115,,86.48,Fee Schedule,115% of CMS OPPS Rate,20.59,58.05,
TDAP ADDL > 18 YEARS OLD,1500299,CDM,450,RC,90472,HCPCS,Outpatient,,,18.00,18.00,,10.58,58.75,,110.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.58,58.75,,110.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.71,48.41,,91.304,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.2,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,8.46,47,,88.648,Percent of Total Billed Charges,47% of Total Billed Charges,16.2,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,10.58,58.75,,110.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,88.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.46,47,,88.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.72,115,,37.6,Fee Schedule,115% of CMS OPPS Rate,14.72,115,,37.6,Fee Schedule,115% of CMS OPPS Rate,8.46,16.2,
REPAIR BLD VES-FINGER/HAND,1500301,CDM,450,RC,35207,HCPCS,Outpatient,,,1072.49,1072.49,,630.09,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,630.09,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,519.19,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,3028.48,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,3028.48,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,504.07,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,3028.48,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,630.09,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,1137.15,100,,,Fee Schedule,100% of ASC Tier Groupings,504.07,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,1137.15,100,,,Fee Schedule,100% ASC Tier Groupings,504.07,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,766.74,115,,12.032,Fee Schedule,115% of CMS OPPS Rate,766.74,115,,12.032,Fee Schedule,115% of CMS OPPS Rate,504.07,3028.48,
CLSD REDCTN PATELLA W ANES,1500302,CDM,450,RC,27562,HCPCS,Outpatient,,,689.50,689.50,,405.08,58.75,,90.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,405.08,58.75,,90.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,333.79,48.41,,74.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,236.32,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,236.32,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,324.07,47,,72.472,Percent of Total Billed Charges,47% of Total Billed Charges,236.32,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,405.08,58.75,,90.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.76,100,,,Fee Schedule,100% of ASC Tier Groupings,324.07,47,,72.472,Percent of Total Billed Charges,47% of Total Billed charges,86.76,100,,,Fee Schedule,100% ASC Tier Groupings,324.07,47,,72.472,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,503.99,115,,37.6,Fee Schedule,115% of CMS OPPS Rate,503.99,115,,37.6,Fee Schedule,115% of CMS OPPS Rate,86.76,503.99,
BENIGN EXCISION LEIS <0.5CM,1500304,CDM,450,RC,11400,HCPCS,Outpatient,,,171.04,171.04,,100.49,58.75,,167.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,100.49,58.75,,167.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,82.8,48.41,,137.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,667.52,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,667.52,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,80.39,47,,133.856,Percent of Total Billed Charges,47% of Total Billed Charges,667.52,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,100.49,58.75,,167.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.73,100,,,Fee Schedule,100% of ASC Tier Groupings,80.39,47,,133.856,Percent of Total Billed Charges,47% of Total Billed charges,76.73,100,,,Fee Schedule,100% ASC Tier Groupings,80.39,47,,133.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,85.24,115,,65.424,Fee Schedule,115% of CMS OPPS Rate,85.24,115,,65.424,Fee Schedule,115% of CMS OPPS Rate,76.73,667.52,
"FBR, CORNEA W/OUT SLIT LAMP",1500307,CDM,450,RC,65220,HCPCS,Outpatient,,,62.95,62.95,,36.98,58.75,,455.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.98,58.75,,455.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.47,48.41,,375.216,Percent of Total Billed Charges,48.41% of Total Billed Charges,397.6,100,,7.92,fee Schedule,100% of ASC Tier Groupings ,397.6,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,29.59,47,,364.288,Percent of Total Billed Charges,47% of Total Billed Charges,397.6,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,36.98,58.75,,455.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.59,47,,364.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,29.59,47,,364.288,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,41.7,115,,87.984,Fee Schedule,115% of CMS OPPS Rate,41.7,115,,87.984,Fee Schedule,115% of CMS OPPS Rate,29.59,397.6,
SIMPLE ELBOW REDUCTION,1500309,CDM,450,RC,24640,HCPCS,Outpatient,,,25.00,25.00,,14.69,58.75,,41.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.69,58.75,,41.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.1,48.41,,34.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,236.32,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,236.32,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,11.75,47,,33.144,Percent of Total Billed Charges,47% of Total Billed Charges,236.32,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,14.69,58.75,,41.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.34,100,,,Fee Schedule,100% of ASC Tier Groupings,11.75,47,,33.144,Percent of Total Billed Charges,47% of Total Billed charges,48.34,100,,,Fee Schedule,100% ASC Tier Groupings,11.75,47,,33.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.75,115,,100.768,Fee Schedule,115% of CMS OPPS Rate,28.75,115,,100.768,Fee Schedule,115% of CMS OPPS Rate,11.75,236.32,
CLOSED TX/FX OF TOE,1500310,CDM,450,RC,28510,HCPCS,Outpatient,,,191.18,191.18,,112.32,58.75,,195.256,Percent of Total Billed Charges,58.75% of Total Billed Charges,112.32,58.75,,195.256,Percent of Total Billed Charges,58.75% of Total Billed Charges,92.55,48.41,,160.888,Percent of Total Billed Charges,48.41% of Total Billed Charges,236.32,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,236.32,100,,7.92,Fee Schedule,100% of ASC Tier Groupings,89.85,47,,156.208,Percent of Total Billed Charges,47% of Total Billed Charges,236.32,100,,7.92,Fee Schedule,100% of ASC Tier Groupings,112.32,58.75,,195.256,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.99,100,,,Fee Schedule,100% of ASC Tier Groupings,89.85,47,,156.208,Percent of Total Billed Charges,47% of Total Billed charges,61.99,100,,,Fee Schedule,100% ASC Tier Groupings,89.85,47,,156.208,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,125.74,115,,21.432,Fee Schedule,115% of CMS OPPS Rate,125.74,115,,21.432,Fee Schedule,115% of CMS OPPS Rate,61.99,236.32,
EXPL OF PENETRATING WOUND,1500312,CDM,450,RC,20103,HCPCS,Outpatient,,,508.20,508.20,,298.57,58.75,,188,Percent of Total Billed Charges,58.75% of Total Billed Charges,298.57,58.75,,188,Percent of Total Billed Charges,58.75% of Total Billed Charges,246.02,48.41,,154.912,Percent of Total Billed Charges,48.41% of Total Billed Charges,667.52,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,667.52,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,238.85,47,,150.4,Percent of Total Billed Charges,47% of Total Billed Charges,667.52,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,298.57,58.75,,188,Percent of Total Billed Charges,58.75% of Total Billed Charges,261.96,100,,,Fee Schedule,100% of ASC Tier Groupings,238.85,47,,150.4,Percent of Total Billed Charges,47% of Total Billed charges,261.96,100,,,Fee Schedule,100% ASC Tier Groupings,238.85,47,,150.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,348.43,115,,34.576,Fee Schedule,115% of CMS OPPS Rate,348.43,115,,34.576,Fee Schedule,115% of CMS OPPS Rate,238.85,667.52,
RDCTN PHAL W/ MANIP,1500315,CDM,450,RC,28515,HCPCS,Outpatient,,,235.76,235.76,,138.51,58.75,,64.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,138.51,58.75,,64.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,114.13,48.41,,53.288,Percent of Total Billed Charges,48.41% of Total Billed Charges,236.32,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,236.32,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,110.81,47,,51.736,Percent of Total Billed Charges,47% of Total Billed Charges,236.32,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,138.51,58.75,,64.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.93,100,,,Fee Schedule,100% of ASC Tier Groupings,110.81,47,,51.736,Percent of Total Billed Charges,47% of Total Billed charges,84.93,100,,,Fee Schedule,100% ASC Tier Groupings,110.81,47,,51.736,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,149.4,115,,17.672,Fee Schedule,115% of CMS OPPS Rate,149.4,115,,17.672,Fee Schedule,115% of CMS OPPS Rate,84.93,236.32,
BLOOD ALCOHOL/POLICE,1500316,CDM,450,RC,,,Outpatient,,,32.00,32.00,,18.8,58.75,,127.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,127.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,105.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.8,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,15.04,47,,102.272,Percent of Total Billed Charges,47% of Total Billed Charges,28.8,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,58.75,,127.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,102.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,102.272,Percent of Total Billed Charges,47% of Total Billed Charges,2000,100,,,Case Rate,Pays based on per visit rate,15.04,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,2000,
I&D EXTERNAL EAR,1500319,CDM,450,RC,69000,HCPCS,Outpatient,,,192.75,192.75,,113.24,58.75,,205.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,113.24,58.75,,205.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,93.31,48.41,,169.208,Percent of Total Billed Charges,48.41% of Total Billed Charges,667.52,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,667.52,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,90.59,47,,164.28,Percent of Total Billed Charges,47% of Total Billed Charges,667.52,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,113.24,58.75,,205.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,105.69,100,,,Fee Schedule,100% of ASC Tier Groupings,90.59,47,,164.28,Percent of Total Billed Charges,47% of Total Billed charges,105.69,100,,,Fee Schedule,100% ASC Tier Groupings,90.59,47,,164.28,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,126.57,115,,16.128,Fee Schedule,115% of CMS OPPS Rate,126.57,115,,16.128,Fee Schedule,115% of CMS OPPS Rate,90.59,667.52,
NAILBED REPAIR,1500321,CDM,450,RC,11760,HCPCS,Outpatient,,,356.00,356.00,,209.15,58.75,,18.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,209.15,58.75,,18.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,172.34,48.41,,15.104,Percent of Total Billed Charges,48.41% of Total Billed Charges,543.2,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,543.2,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,167.32,47,,14.664,Percent of Total Billed Charges,47% of Total Billed Charges,543.2,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,209.15,58.75,,18.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,103.77,100,,,Fee Schedule,100% of ASC Tier Groupings,167.32,47,,14.664,Percent of Total Billed Charges,47% of Total Billed charges,103.77,100,,,Fee Schedule,100% ASC Tier Groupings,167.32,47,,14.664,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,111.76,115,,39.48,Fee Schedule,115% of CMS OPPS Rate,111.76,115,,39.48,Fee Schedule,115% of CMS OPPS Rate,103.77,543.2,
NAILBED REPAIR PF,1500322,CDM,450,RC,11760,HCPCS,Outpatient,,,968.85,968.85,,569.2,58.75,,37.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,569.2,58.75,,37.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,469.02,48.41,,30.928,Percent of Total Billed Charges,48.41% of Total Billed Charges,543.2,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,543.2,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,455.36,47,,30.024,Percent of Total Billed Charges,47% of Total Billed Charges,543.2,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,569.2,58.75,,37.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,103.77,100,,,Fee Schedule,100% of ASC Tier Groupings,455.36,47,,30.024,Percent of Total Billed Charges,47% of Total Billed charges,103.77,100,,,Fee Schedule,100% ASC Tier Groupings,455.36,47,,30.024,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,111.76,115,,15.416,Fee Schedule,115% of CMS OPPS Rate,111.76,115,,15.416,Fee Schedule,115% of CMS OPPS Rate,103.77,569.2,
INSERTION OF INTRAOSSEOUS LINE,1500323,CDM,450,RC,36680,HCPCS,Outpatient,,,88.14,88.14,,51.78,58.75,,24.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.78,58.75,,24.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.67,48.41,,20.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,397.6,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,397.6,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,41.43,47,,19.816,Percent of Total Billed Charges,47% of Total Billed Charges,397.6,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,51.78,58.75,,24.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,41.43,47,,19.816,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,41.43,47,,19.816,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,60.51,115,,35.344,Fee Schedule,115% of CMS OPPS Rate,60.51,115,,35.344,Fee Schedule,115% of CMS OPPS Rate,41.43,397.6,
RED SHLD DISLOCATION,1500324,CDM,450,RC,23650,HCPCS,Outpatient,,,415.44,415.44,,244.07,58.75,,218.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,244.07,58.75,,218.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,201.11,48.41,,179.696,Percent of Total Billed Charges,48.41% of Total Billed Charges,236.32,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,236.32,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,195.26,47,,174.464,Percent of Total Billed Charges,47% of Total Billed Charges,236.32,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,244.07,58.75,,218.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.76,100,,,Fee Schedule,100% of ASC Tier Groupings,195.26,47,,174.464,Percent of Total Billed Charges,47% of Total Billed charges,86.76,100,,,Fee Schedule,100% ASC Tier Groupings,195.26,47,,174.464,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,313.44,115,,53.392,Fee Schedule,115% of CMS OPPS Rate,313.44,115,,53.392,Fee Schedule,115% of CMS OPPS Rate,86.76,313.44,
G TUBE REPLACEMENT,1500325,CDM,450,RC,43762,HCPCS,Outpatient,,,400.00,400.00,,235,58.75,,373.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,235,58.75,,373.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,193.64,48.41,,307.504,Percent of Total Billed Charges,48.41% of Total Billed Charges,257.6,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,257.6,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,188,47,,298.544,Percent of Total Billed Charges,47% of Total Billed Charges,257.6,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,235,58.75,,373.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,112.02,100,,,Fee Schedule,100% of ASC Tier Groupings,188,47,,298.544,Percent of Total Billed Charges,47% of Total Billed charges,112.02,100,,,Fee Schedule,100% ASC Tier Groupings,188,47,,298.544,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.82,115,,73.32,Fee Schedule,115% of CMS OPPS Rate,37.82,115,,73.32,Fee Schedule,115% of CMS OPPS Rate,37.82,257.6,
CAUTERY OF NOSE BLEED,1500326,CDM,450,RC,30901,HCPCS,Outpatient,,,137.60,137.60,,80.84,58.75,,79.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,80.84,58.75,,79.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.61,48.41,,65.248,Percent of Total Billed Charges,48.41% of Total Billed Charges,119.84,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,119.84,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,64.67,47,,63.352,Percent of Total Billed Charges,47% of Total Billed Charges,119.84,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,80.84,58.75,,79.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,64.67,47,,63.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,64.67,47,,63.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,57.5,115,,87.984,Fee Schedule,115% of CMS OPPS Rate,57.5,115,,87.984,Fee Schedule,115% of CMS OPPS Rate,57.5,119.84,
HIP REDUCTION,1500327,CDM,450,RC,27250,HCPCS,Outpatient,,,272.00,272.00,,159.8,58.75,,249.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,159.8,58.75,,249.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,131.68,48.41,,205.416,Percent of Total Billed Charges,48.41% of Total Billed Charges,236.32,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,236.32,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,127.84,47,,199.432,Percent of Total Billed Charges,47% of Total Billed Charges,236.32,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,159.8,58.75,,249.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.76,100,,,Fee Schedule,100% of ASC Tier Groupings,127.84,47,,199.432,Percent of Total Billed Charges,47% of Total Billed charges,86.76,100,,,Fee Schedule,100% ASC Tier Groupings,127.84,47,,199.432,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,182.14,115,,47.376,Fee Schedule,115% of CMS OPPS Rate,182.14,115,,47.376,Fee Schedule,115% of CMS OPPS Rate,86.76,236.32,
RED OF METARCARPOPHALANGEAL JT,1500328,CDM,450,RC,26700,HCPCS,Outpatient,,,436.92,436.92,,256.69,58.75,,66.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,256.69,58.75,,66.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,211.51,48.41,,54.664,Percent of Total Billed Charges,48.41% of Total Billed Charges,236.32,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,236.32,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,205.35,47,,53.072,Percent of Total Billed Charges,47% of Total Billed Charges,236.32,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,256.69,58.75,,66.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.76,100,,,Fee Schedule,100% of ASC Tier Groupings,205.35,47,,53.072,Percent of Total Billed Charges,47% of Total Billed charges,86.76,100,,,Fee Schedule,100% ASC Tier Groupings,205.35,47,,53.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,327.62,115,,15.04,Fee Schedule,115% of CMS OPPS Rate,327.62,115,,15.04,Fee Schedule,115% of CMS OPPS Rate,86.76,327.62,
DEBRIDEMENT OF SKIN,1500329,CDM,450,RC,97597,HCPCS,Outpatient,,,39.00,39.00,,22.91,58.75,,23.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.91,58.75,,23.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.88,48.41,,19.368,Percent of Total Billed Charges,48.41% of Total Billed Charges,167.75,100,,0.008,fee Schedule,100% of BCBS fee schedule,167.75,100,,0.008,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,18.33,47,,18.8,Percent of Total Billed Charges,47% of Total Billed Charges,167.75,100,,0.008,Fee Schedule,100% of BCBS PPO fee schedule,22.91,58.75,,23.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.33,47,,18.8,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.33,47,,18.8,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,36.96,115,,53.016,Fee Schedule,115% of CMS OPPS Rate,36.96,115,,53.016,Fee Schedule,115% of CMS OPPS Rate,18.33,167.75,
BIOPSY SKIN LESION,1500330,CDM,450,RC,11100,HCPCS,Outpatient,,,79.85,79.85,,46.91,58.75,,176.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.91,58.75,,176.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.66,48.41,,145.544,Percent of Total Billed Charges,48.41% of Total Billed Charges,71.87,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,71.87,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,37.53,47,,141.304,Percent of Total Billed Charges,47% of Total Billed Charges,71.87,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,46.91,58.75,,176.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.53,47,,141.304,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,37.53,47,,141.304,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.53,47,,19.024,Percent of Total Billed Charges,47% of Total Billed Charges,37.53,47,,19.024,Percent of Total Billed Charges,47% of Total Billed Charges,37.53,71.87,
CLOSED TMJ REDUCTION,1500331,CDM,450,RC,21480,HCPCS,Outpatient,,,52.70,52.70,,30.96,58.75,,126.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.96,58.75,,126.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.51,48.41,,104.608,Percent of Total Billed Charges,48.41% of Total Billed Charges,236.32,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,236.32,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,24.77,47,,101.56,Percent of Total Billed Charges,47% of Total Billed Charges,236.32,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,30.96,58.75,,126.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.76,100,,,Fee Schedule,100% of ASC Tier Groupings,24.77,47,,101.56,Percent of Total Billed Charges,47% of Total Billed charges,86.76,100,,,Fee Schedule,100% ASC Tier Groupings,24.77,47,,101.56,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.91,115,,51.704,Fee Schedule,115% of CMS OPPS Rate,31.91,115,,51.704,Fee Schedule,115% of CMS OPPS Rate,24.77,236.32,
I & D OF VULVA/PERINEUM,1500332,CDM,450,RC,56405,HCPCS,Outpatient,,,464.00,464.00,,272.6,58.75,,462.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,272.6,58.75,,462.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,224.62,48.41,,381.472,Percent of Total Billed Charges,48.41% of Total Billed Charges,296.8,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,296.8,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,218.08,47,,370.36,Percent of Total Billed Charges,47% of Total Billed Charges,296.8,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,272.6,58.75,,462.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.54,100,,,Fee Schedule,100% of ASC Tier Groupings,218.08,47,,370.36,Percent of Total Billed Charges,47% of Total Billed charges,74.54,100,,,Fee Schedule,100% ASC Tier Groupings,218.08,47,,370.36,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,127.48,115,,20.024,Fee Schedule,115% of CMS OPPS Rate,127.48,115,,20.024,Fee Schedule,115% of CMS OPPS Rate,74.54,296.8,
CLOSD REDUCTION RADIUS/ULNA FX,1500333,CDM,450,RC,25605,HCPCS,Outpatient,,,794.00,794.00,,466.48,58.75,,159.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,466.48,58.75,,159.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,384.38,48.41,,131.112,Percent of Total Billed Charges,48.41% of Total Billed Charges,1481.76,100,,90.72,fee Schedule,100% of ASC Tier Groupings ,1481.76,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,373.18,47,,127.296,Percent of Total Billed Charges,47% of Total Billed Charges,1481.76,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,466.48,58.75,,159.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,603.08,100,,,Fee Schedule,100% of ASC Tier Groupings,373.18,47,,127.296,Percent of Total Billed Charges,47% of Total Billed charges,603.08,100,,,Fee Schedule,100% ASC Tier Groupings,373.18,47,,127.296,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,526,115,,32.672,Fee Schedule,115% of CMS OPPS Rate,526,115,,32.672,Fee Schedule,115% of CMS OPPS Rate,373.18,1481.76,
POSTERIOR NOSE PACKING,1500334,CDM,450,RC,30905,HCPCS,Outpatient,,,168.48,168.48,,98.98,58.75,,128.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,98.98,58.75,,128.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,81.56,48.41,,106.248,Percent of Total Billed Charges,48.41% of Total Billed Charges,119.84,100,,65.344,fee Schedule,100% of ASC Tier Groupings ,119.84,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,79.19,47,,103.152,Percent of Total Billed Charges,47% of Total Billed Charges,119.84,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,98.98,58.75,,128.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.47,100,,,Fee Schedule,100% of ASC Tier Groupings,79.19,47,,103.152,Percent of Total Billed Charges,47% of Total Billed charges,47.47,100,,,Fee Schedule,100% ASC Tier Groupings,79.19,47,,103.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,107.72,115,,58.656,Fee Schedule,115% of CMS OPPS Rate,107.72,115,,58.656,Fee Schedule,115% of CMS OPPS Rate,47.47,119.84,
INJ FEE TPA ADMIN,1500335,CDM,450,RC,37212,HCPCS,Outpatient,,,530.41,530.41,,311.62,58.75,,138.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,311.62,58.75,,138.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,256.77,48.41,,114.272,Percent of Total Billed Charges,48.41% of Total Billed Charges,3028.48,100,,6.48,fee Schedule,100% of ASC Tier Groupings ,3028.48,100,,90.72,Fee Schedule,100% of ASC Tier Groupings,249.29,47,,110.944,Percent of Total Billed Charges,47% of Total Billed Charges,3028.48,100,,90.72,Fee Schedule,100% of ASC Tier Groupings,311.62,58.75,,138.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,1543.86,100,,,Fee Schedule,100% of ASC Tier Groupings,249.29,47,,110.944,Percent of Total Billed Charges,47% of Total Billed charges,1543.86,100,,,Fee Schedule,100% ASC Tier Groupings,249.29,47,,110.944,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,336.96,115,,10.152,Fee Schedule,115% of CMS OPPS Rate,336.96,115,,10.152,Fee Schedule,115% of CMS OPPS Rate,249.29,3028.48,
CLSD REDCTN INTERPHALANGEAL JT,1500336,CDM,450,RC,28660,HCPCS,Outpatient,,,141.15,141.15,,82.93,58.75,,157.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,82.93,58.75,,157.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,68.33,48.41,,129.736,Percent of Total Billed Charges,48.41% of Total Billed Charges,236.32,100,,12.24,fee Schedule,100% of ASC Tier Groupings ,236.32,100,,65.344,Fee Schedule,100% of ASC Tier Groupings,66.34,47,,125.96,Percent of Total Billed Charges,47% of Total Billed Charges,236.32,100,,65.344,Fee Schedule,100% of ASC Tier Groupings,82.93,58.75,,157.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.44,100,,,Fee Schedule,100% of ASC Tier Groupings,66.34,47,,125.96,Percent of Total Billed Charges,47% of Total Billed charges,58.44,100,,,Fee Schedule,100% ASC Tier Groupings,66.34,47,,125.96,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,96.19,115,,48.448,Fee Schedule,115% of CMS OPPS Rate,96.19,115,,48.448,Fee Schedule,115% of CMS OPPS Rate,58.44,236.32,
EVACUATION SUBUNGUAL HEMATOMA,1500337,CDM,450,RC,11740,HCPCS,Outpatient,,,50.00,50.00,,29.38,58.75,,67.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.38,58.75,,67.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.21,48.41,,55.768,Percent of Total Billed Charges,48.41% of Total Billed Charges,119.84,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,119.84,100,,6.48,Fee Schedule,100% of ASC Tier Groupings,23.5,47,,54.144,Percent of Total Billed Charges,47% of Total Billed Charges,119.84,100,,6.48,Fee Schedule,100% of ASC Tier Groupings,29.38,58.75,,67.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.5,47,,54.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.5,47,,54.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.21,115,,42.488,Fee Schedule,115% of CMS OPPS Rate,33.21,115,,42.488,Fee Schedule,115% of CMS OPPS Rate,23.5,119.84,
OBS SUBSQ MOD,1500338,CDM,982,RC,99225,HCPCS,Outpatient,,,135.00,135.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
CLOSED RED OF LITTLE FINGER,1500339,CDM,450,RC,26755,HCPCS,Outpatient,,,375.81,375.81,,220.79,58.75,,50.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,220.79,58.75,,50.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,181.93,48.41,,41.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,236.32,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,236.32,100,,44.64,Fee Schedule,100% of ASC Tier Groupings,176.63,47,,40.536,Percent of Total Billed Charges,47% of Total Billed Charges,236.32,100,,44.64,Fee Schedule,100% of ASC Tier Groupings,220.79,58.75,,50.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.76,100,,,Fee Schedule,100% of ASC Tier Groupings,176.63,47,,40.536,Percent of Total Billed Charges,47% of Total Billed charges,86.76,100,,,Fee Schedule,100% ASC Tier Groupings,176.63,47,,40.536,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,287.95,115,,50.384,Fee Schedule,115% of CMS OPPS Rate,287.95,115,,50.384,Fee Schedule,115% of CMS OPPS Rate,86.76,287.95,
I&D FELON OF THE FINGER,1500340,CDM,450,RC,26011,HCPCS,Outpatient,,,270.10,270.10,,158.68,58.75,,63.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,158.68,58.75,,63.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,130.76,48.41,,52.672,Percent of Total Billed Charges,48.41% of Total Billed Charges,1500.8,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,1500.8,100,,9.36,Fee Schedule,100% of ASC Tier Groupings,126.95,47,,51.136,Percent of Total Billed Charges,47% of Total Billed Charges,1500.8,100,,9.36,Fee Schedule,100% of ASC Tier Groupings,158.68,58.75,,63.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,494.68,100,,,Fee Schedule,100% of ASC Tier Groupings,126.95,47,,51.136,Percent of Total Billed Charges,47% of Total Billed charges,494.68,100,,,Fee Schedule,100% ASC Tier Groupings,126.95,47,,51.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,188.03,115,,54.048,Fee Schedule,115% of CMS OPPS Rate,188.03,115,,54.048,Fee Schedule,115% of CMS OPPS Rate,126.95,1500.8,
RED SHOULDER DISLOCAT W FRACT,1500341,CDM,450,RC,23675,HCPCS,Outpatient,,,985.00,985.00,,578.69,58.75,,31.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,578.69,58.75,,31.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,476.84,48.41,,26.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,1481.76,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,1481.76,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,462.95,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,1481.76,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,578.69,58.75,,31.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,603.08,100,,,Fee Schedule,100% of ASC Tier Groupings,462.95,47,,25.568,Percent of Total Billed Charges,47% of Total Billed charges,603.08,100,,,Fee Schedule,100% ASC Tier Groupings,462.95,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,515.15,115,,21.432,Fee Schedule,115% of CMS OPPS Rate,515.15,115,,21.432,Fee Schedule,115% of CMS OPPS Rate,462.95,1481.76,
TREAT METACARPAL FRACTURE,1500342,CDM,450,RC,26605,HCPCS,Outpatient,,,338.55,338.55,,198.9,58.75,,18.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,198.9,58.75,,18.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,163.89,48.41,,15.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,236.32,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,236.32,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,159.12,47,,14.888,Percent of Total Billed Charges,47% of Total Billed Charges,236.32,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,198.9,58.75,,18.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.76,100,,,Fee Schedule,100% of ASC Tier Groupings,159.12,47,,14.888,Percent of Total Billed Charges,47% of Total Billed charges,86.76,100,,,Fee Schedule,100% ASC Tier Groupings,159.12,47,,14.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,309.18,115,,68.056,Fee Schedule,115% of CMS OPPS Rate,309.18,115,,68.056,Fee Schedule,115% of CMS OPPS Rate,86.76,309.18,
SHAVED BIOPSY OF SKIN,1500343,CDM,450,RC,11102,HCPCS,Outpatient,,,274.35,274.35,,161.18,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,161.18,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,132.81,48.41,,37.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,128.94,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,161.18,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,63.35,100,,,Fee Schedule,100% of ASC Tier Groupings,128.94,47,,36.848,Percent of Total Billed Charges,47% of Total Billed charges,63.35,100,,,Fee Schedule,100% ASC Tier Groupings,128.94,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.5,115,,63.544,Fee Schedule,115% of CMS OPPS Rate,38.5,115,,63.544,Fee Schedule,115% of CMS OPPS Rate,38.5,191.52,
INT REP OTF 2.6-7.5,1500347,CDM,450,RC,12032,HCPCS,Outpatient,,,295.07,295.07,,173.35,58.75,,183.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,173.35,58.75,,183.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,142.84,48.41,,151.04,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,138.68,47,,146.64,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,173.35,58.75,,183.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,138.68,47,,146.64,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,138.68,47,,146.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,193.37,115,,74.616,Fee Schedule,115% of CMS OPPS Rate,193.37,115,,74.616,Fee Schedule,115% of CMS OPPS Rate,138.68,349.44,
I&D OF SCROTUM,1500348,CDM,450,RC,54700,HCPCS,Outpatient,,,335.00,335.00,,196.81,58.75,,78.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,196.81,58.75,,78.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,162.17,48.41,,64.672,Percent of Total Billed Charges,48.41% of Total Billed Charges,1936.48,100,,0.008,fee Schedule,100% of ASC Tier Groupings ,1936.48,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,157.45,47,,62.792,Percent of Total Billed Charges,47% of Total Billed Charges,1936.48,100,,0.008,Fee Schedule,100% of ASC Tier Groupings,196.81,58.75,,78.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,663.84,100,,,Fee Schedule,100% of ASC Tier Groupings,157.45,47,,62.792,Percent of Total Billed Charges,47% of Total Billed charges,663.84,100,,,Fee Schedule,100% ASC Tier Groupings,157.45,47,,62.792,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,219.13,115,,39.704,Fee Schedule,115% of CMS OPPS Rate,219.13,115,,39.704,Fee Schedule,115% of CMS OPPS Rate,157.45,1936.48,
CAST LONG ARM CHILD,1510073,CDM,270,RC,,,Outpatient,,,144.00,144.00,,84.6,58.75,,86.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.6,58.75,,86.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.71,48.41,,70.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,129.6,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,129.6,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,67.68,47,,68.808,Percent of Total Billed Charges,47% of Total Billed Charges,129.6,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,84.6,58.75,,86.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,67.68,47,,68.808,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,67.68,47,,68.808,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,67.68,47,,48.128,Percent of Total Billed Charges,47% of Total Billed Charges,67.68,47,,48.128,Percent of Total Billed Charges,47% of Total Billed Charges,67.68,129.6,
WRITTEN/PHONE ORDER,1510077,CDM,450,RC,99282,HCPCS,Outpatient,,,28.00,28.00,,16.45,58.75,,56.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,56.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,46.472,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.2,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,47,,45.12,Percent of Total Billed Charges,47% of Total Billed Charges,25.2,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,58.75,,56.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,45.12,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,45.12,Percent of Total Billed Charges,47% of Total Billed Charges,283,100,,,Case Rate,Pays based on per visit rate,32.2,115,,75.952,Fee Schedule,115% of CMS OPPS Rate,32.2,115,,75.952,Fee Schedule,115% of CMS OPPS Rate,13.16,283,
CAST SHORT ARM CHILD,1510078,CDM,270,RC,,,Outpatient,,,107.80,107.80,,63.33,58.75,,65.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,63.33,58.75,,65.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,52.19,48.41,,54.216,Percent of Total Billed Charges,48.41% of Total Billed Charges,97.02,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,97.02,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,50.67,47,,52.64,Percent of Total Billed Charges,47% of Total Billed Charges,97.02,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,63.33,58.75,,65.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,50.67,47,,52.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,50.67,47,,52.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,50.67,47,,67.68,Percent of Total Billed Charges,47% of Total Billed Charges,50.67,47,,67.68,Percent of Total Billed Charges,47% of Total Billed Charges,50.67,97.02,
CAST LONG LEG CHILD,1510079,CDM,270,RC,,,Outpatient,,,136.00,136.00,,79.9,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.9,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,65.84,48.41,,36.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,122.4,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,122.4,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,63.92,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,122.4,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,79.9,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,63.92,47,,35.344,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,63.92,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,63.92,47,,31.4,Percent of Total Billed Charges,47% of Total Billed Charges,63.92,47,,31.4,Percent of Total Billed Charges,47% of Total Billed Charges,63.92,122.4,
E R TRAY SMALL,1510081,CDM,270,RC,,,Outpatient,,,68.00,68.00,,39.95,58.75,,14.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.95,58.75,,14.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.92,48.41,,12.008,Percent of Total Billed Charges,48.41% of Total Billed Charges,61.2,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,61.2,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,31.96,47,,11.656,Percent of Total Billed Charges,47% of Total Billed Charges,61.2,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,39.95,58.75,,14.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.96,47,,11.656,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.96,47,,11.656,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.96,47,,56.568,Percent of Total Billed Charges,47% of Total Billed Charges,31.96,47,,56.568,Percent of Total Billed Charges,47% of Total Billed Charges,31.96,61.2,
CAST REMOVAL,1510083,CDM,270,RC,,,Outpatient,,,39.60,39.60,,23.27,58.75,,24.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.27,58.75,,24.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.17,48.41,,20.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,35.64,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,35.64,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,18.61,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,35.64,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,23.27,58.75,,24.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.61,47,,19.552,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.61,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.61,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,18.61,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,18.61,35.64,
CAST SHORT LEG CHILD,1510086,CDM,270,RC,,,Outpatient,,,98.00,98.00,,57.58,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.58,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.44,48.41,,8.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,88.2,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,88.2,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,46.06,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,88.2,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,57.58,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.06,47,,8.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,46.06,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.06,47,,12.784,Percent of Total Billed Charges,47% of Total Billed Charges,46.06,47,,12.784,Percent of Total Billed Charges,47% of Total Billed Charges,46.06,88.2,
CAST HAND & FOREARM,1510089,CDM,270,RC,,,Outpatient,,,390.00,390.00,,229.13,58.75,,139.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,229.13,58.75,,139.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,188.8,48.41,,114.632,Percent of Total Billed Charges,48.41% of Total Billed Charges,351,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,351,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,183.3,47,,111.296,Percent of Total Billed Charges,47% of Total Billed Charges,351,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,229.13,58.75,,139.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,183.3,47,,111.296,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,183.3,47,,111.296,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,183.3,47,,39.648,Percent of Total Billed Charges,47% of Total Billed Charges,183.3,47,,39.648,Percent of Total Billed Charges,47% of Total Billed Charges,183.3,351,
CAST LONG ARM ADULT,1510090,CDM,270,RC,,,Outpatient,,,167.00,167.00,,98.11,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,98.11,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,80.84,48.41,,49.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,150.3,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,150.3,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,78.49,47,,47.752,Percent of Total Billed Charges,47% of Total Billed Charges,150.3,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,98.11,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,78.49,47,,47.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,78.49,47,,47.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,78.49,47,,36.04,Percent of Total Billed Charges,47% of Total Billed Charges,78.49,47,,36.04,Percent of Total Billed Charges,47% of Total Billed Charges,78.49,150.3,
CAST LONG LEG ADULT,1510091,CDM,270,RC,,,Outpatient,,,183.00,183.00,,107.51,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,107.51,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,88.59,48.41,,12.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,164.7,90,,77.04,Percent of Total Billed Charges,90% of Total Billed Charges,164.7,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,86.01,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,164.7,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,107.51,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,86.01,47,,12.408,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,86.01,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,86.01,47,,50.76,Percent of Total Billed Charges,47% of Total Billed Charges,86.01,47,,50.76,Percent of Total Billed Charges,47% of Total Billed Charges,86.01,164.7,
CAST SHORT ARM ADULT,1510092,CDM,270,RC,,,Outpatient,,,120.00,120.00,,70.5,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,70.5,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.09,48.41,,116.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,108,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,108,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,56.4,47,,112.8,Percent of Total Billed Charges,47% of Total Billed Charges,108,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,70.5,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,56.4,47,,112.8,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,56.4,47,,112.8,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,56.4,47,,70.064,Percent of Total Billed Charges,47% of Total Billed Charges,56.4,47,,70.064,Percent of Total Billed Charges,47% of Total Billed Charges,56.4,108,
CAST SHORT LEG ADULT,1510093,CDM,270,RC,,,Outpatient,,,140.00,140.00,,82.25,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,82.25,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,67.77,48.41,,11.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,126,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,126,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,65.8,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,126,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,82.25,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,65.8,47,,11.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,65.8,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,65.8,47,,29.368,Percent of Total Billed Charges,47% of Total Billed Charges,65.8,47,,29.368,Percent of Total Billed Charges,47% of Total Billed Charges,65.8,126,
EAR REM IMP CERUMEN,1510101,CDM,270,RC,,,Outpatient,,,94.00,94.00,,55.23,58.75,,30.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,55.23,58.75,,30.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.51,48.41,,25.176,Percent of Total Billed Charges,48.41% of Total Billed Charges,84.6,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,84.6,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,44.18,47,,24.44,Percent of Total Billed Charges,47% of Total Billed Charges,84.6,90,,0.008,Percent of Total Billed Charges,90% of Total Billed Charges,55.23,58.75,,30.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,44.18,47,,24.44,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,44.18,47,,24.44,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,44.18,47,,37.64,Percent of Total Billed Charges,47% of Total Billed Charges,44.18,47,,37.64,Percent of Total Billed Charges,47% of Total Billed Charges,44.18,84.6,
EYE TRAY,1510111,CDM,270,RC,,,Outpatient,,,31.00,31.00,,18.21,58.75,,97.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.21,58.75,,97.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.01,48.41,,80.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,27.9,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,27.9,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,14.57,47,,78.208,Percent of Total Billed Charges,47% of Total Billed Charges,27.9,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,18.21,58.75,,97.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.57,47,,78.208,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.57,47,,78.208,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.57,47,,56.4,Percent of Total Billed Charges,47% of Total Billed Charges,14.57,47,,56.4,Percent of Total Billed Charges,47% of Total Billed Charges,14.57,27.9,
E R TRAY LARGE,1510121,CDM,270,RC,,,Outpatient,,,52.00,52.00,,30.55,58.75,,47.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.55,58.75,,47.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.17,48.41,,39.504,Percent of Total Billed Charges,48.41% of Total Billed Charges,46.8,90,,93.6,Percent of Total Billed Charges,90% of Total Billed Charges,46.8,90,,77.04,Percent of Total Billed Charges,90% of Total Billed Charges,24.44,47,,38.352,Percent of Total Billed Charges,47% of Total Billed Charges,46.8,90,,77.04,Percent of Total Billed Charges,90% of Total Billed Charges,30.55,58.75,,47.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.44,47,,38.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,24.44,47,,38.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.44,47,,35.232,Percent of Total Billed Charges,47% of Total Billed Charges,24.44,47,,35.232,Percent of Total Billed Charges,47% of Total Billed Charges,24.44,46.8,
GASTRIC LAVAGE TRAY,1510163,CDM,270,RC,,,Outpatient,,,23.00,23.00,,13.51,58.75,,233.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.51,58.75,,233.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.13,48.41,,192.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.7,90,,13.248,Percent of Total Billed Charges,90% of Total Billed Charges,20.7,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,10.81,47,,186.872,Percent of Total Billed Charges,47% of Total Billed Charges,20.7,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,13.51,58.75,,233.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,186.872,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.81,47,,186.872,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,35.72,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,47,,35.72,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,20.7,
FB REM NOSE SIMPLE,1510171,CDM,450,RC,30300,HCPCS,Outpatient,,,296.00,296.00,,173.9,58.75,,209.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,173.9,58.75,,209.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,143.29,48.41,,172.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,119.84,100,,9,fee Schedule,100% of ASC Tier Groupings ,119.84,100,,8.64,Fee Schedule,100% of ASC Tier Groupings,139.12,47,,167.696,Percent of Total Billed Charges,47% of Total Billed Charges,119.84,100,,8.64,Fee Schedule,100% of ASC Tier Groupings,173.9,58.75,,209.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,139.12,47,,167.696,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,139.12,47,,167.696,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,120.72,115,,42.864,Fee Schedule,115% of CMS OPPS Rate,120.72,115,,42.864,Fee Schedule,115% of CMS OPPS Rate,119.84,173.9,
LUMBAR PUNCTURE,1510185,CDM,450,RC,,,Outpatient,,,127.00,127.00,,74.61,58.75,,474.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.61,58.75,,474.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.48,48.41,,391.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,114.3,90,,336.96,Percent of Total Billed Charges,90% of Total Billed Charges,114.3,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,59.69,47,,379.76,Percent of Total Billed Charges,47% of Total Billed Charges,114.3,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,74.61,58.75,,474.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,59.69,47,,379.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,59.69,47,,379.76,Percent of Total Billed Charges,47% of Total Billed Charges,2000,100,,,Case Rate,Pays based on per visit rate,59.69,47,,20.024,Percent of Total Billed Charges,47% of Total Billed Charges,59.69,47,,20.024,Percent of Total Billed Charges,47% of Total Billed Charges,59.69,2000,
TRACHEOTOMY TUBE,1510194,CDM,270,RC,,,Outpatient,,,33.00,33.00,,19.39,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.39,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.98,48.41,,116.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,29.7,90,,228.96,Percent of Total Billed Charges,90% of Total Billed Charges,29.7,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,15.51,47,,112.8,Percent of Total Billed Charges,47% of Total Billed Charges,29.7,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,19.39,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,112.8,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.51,47,,112.8,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,29.7,
I&D ABSCESS SIMPLE,1510198,CDM,450,RC,10060,HCPCS,Outpatient,,,300.00,300.00,,176.25,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,176.25,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.23,48.41,,116.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,165.6,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,93.6,Fee Schedule,100% of ASC Tier Groupings,141,47,,112.8,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,93.6,Fee Schedule,100% of ASC Tier Groupings,176.25,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.17,100,,,Fee Schedule,100% of ASC Tier Groupings,141,47,,112.8,Percent of Total Billed Charges,47% of Total Billed charges,64.17,100,,,Fee Schedule,100% ASC Tier Groupings,141,47,,112.8,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,108.34,115,,80.84,Fee Schedule,115% of CMS OPPS Rate,108.34,115,,80.84,Fee Schedule,115% of CMS OPPS Rate,64.17,191.52,
INSTR INDIV. WRAPPED,1510224,CDM,270,RC,,,Outpatient,,,30.00,30.00,,17.63,58.75,,95.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.63,58.75,,95.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.52,48.41,,78.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,27,90,,277.2,Percent of Total Billed Charges,90% of Total Billed Charges,27,90,,13.248,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,47,,76.328,Percent of Total Billed Charges,47% of Total Billed Charges,27,90,,13.248,Percent of Total Billed Charges,90% of Total Billed Charges,17.63,58.75,,95.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,76.328,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.1,47,,76.328,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,27,
PELVIC EXAM,1510247,CDM,450,RC,99459,HCPCS,Outpatient,1,UN,65.00,65.00,,38.19,58.75,,256.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.19,58.75,,256.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.47,48.41,,211.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,58.5,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,58.5,90,,9,Percent of Total Billed Charges,90% of Total Billed Charges,30.55,47,,205.296,Percent of Total Billed Charges,47% of Total Billed Charges,58.5,90,,9,Percent of Total Billed Charges,90% of Total Billed Charges,38.19,58.75,,256.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.55,47,,205.296,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,30.55,47,,205.296,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.47,115,,53.016,Fee Schedule,115% of CMS OPPS Rate,20.47,115,,53.016,Fee Schedule,115% of CMS OPPS Rate,20.47,58.5,
SPLINT LOWER EXTREM,1510248,CDM,270,RC,,,Outpatient,,,208.00,208.00,,122.2,58.75,,117.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,122.2,58.75,,117.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,100.69,48.41,,96.432,Percent of Total Billed Charges,48.41% of Total Billed Charges,187.2,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,187.2,90,,336.96,Percent of Total Billed Charges,90% of Total Billed Charges,97.76,47,,93.624,Percent of Total Billed Charges,47% of Total Billed Charges,187.2,90,,336.96,Percent of Total Billed Charges,90% of Total Billed Charges,122.2,58.75,,117.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,97.76,47,,93.624,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,97.76,47,,93.624,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,97.76,47,,51.512,Percent of Total Billed Charges,47% of Total Billed Charges,97.76,47,,51.512,Percent of Total Billed Charges,47% of Total Billed Charges,97.76,187.2,
INSERT NG TUBE,1510269,CDM,450,RC,,,Outpatient,,,102.00,102.00,,59.93,58.75,,109.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,59.93,58.75,,109.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.38,48.41,,90.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,91.8,90,,99.504,Percent of Total Billed Charges,90% of Total Billed Charges,91.8,90,,228.96,Percent of Total Billed Charges,90% of Total Billed Charges,47.94,47,,87.984,Percent of Total Billed Charges,47% of Total Billed Charges,91.8,90,,228.96,Percent of Total Billed Charges,90% of Total Billed Charges,59.93,58.75,,109.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47.94,47,,87.984,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47.94,47,,87.984,Percent of Total Billed Charges,47% of Total Billed Charges,2000,100,,,Case Rate,Pays based on per visit rate,47.94,47,,76.328,Percent of Total Billed Charges,47% of Total Billed Charges,47.94,47,,76.328,Percent of Total Billed Charges,47% of Total Billed Charges,47.94,2000,
NOSE ANTERIOR PACK,1510343,CDM,450,RC,,,Outpatient,,,497.00,497.00,,291.99,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,291.99,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,240.6,48.41,,116.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,447.3,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,447.3,90,,165.6,Percent of Total Billed Charges,90% of Total Billed Charges,233.59,47,,112.8,Percent of Total Billed Charges,47% of Total Billed Charges,447.3,90,,165.6,Percent of Total Billed Charges,90% of Total Billed Charges,291.99,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,233.59,47,,112.8,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,233.59,47,,112.8,Percent of Total Billed Charges,47% of Total Billed Charges,2000,100,,,Case Rate,Pays based on per visit rate,233.59,47,,160.024,Percent of Total Billed Charges,47% of Total Billed Charges,233.59,47,,160.024,Percent of Total Billed Charges,47% of Total Billed Charges,233.59,2000,
NOSE POSTERIOR PACK,1510344,CDM,450,RC,,,Outpatient,,,446.00,446.00,,262.03,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,262.03,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,215.91,48.41,,116.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,401.4,90,,198.72,Percent of Total Billed Charges,90% of Total Billed Charges,401.4,90,,277.2,Percent of Total Billed Charges,90% of Total Billed Charges,209.62,47,,112.8,Percent of Total Billed Charges,47% of Total Billed Charges,401.4,90,,277.2,Percent of Total Billed Charges,90% of Total Billed Charges,262.03,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,209.62,47,,112.8,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,209.62,47,,112.8,Percent of Total Billed Charges,47% of Total Billed Charges,2000,100,,,Case Rate,Pays based on per visit rate,209.62,47,,81.48,Percent of Total Billed Charges,47% of Total Billed Charges,209.62,47,,81.48,Percent of Total Billed Charges,47% of Total Billed Charges,209.62,2000,
DELIVERY IN ER,1510346,CDM,450,RC,,,Outpatient,,,1010.00,1010.00,,593.38,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,593.38,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,488.94,48.41,,116.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,909,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,909,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,474.7,47,,112.8,Percent of Total Billed Charges,47% of Total Billed Charges,909,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,593.38,58.75,,141,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,474.7,47,,112.8,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,474.7,47,,112.8,Percent of Total Billed Charges,47% of Total Billed Charges,2000,100,,,Case Rate,Pays based on per visit rate,474.7,47,,62.792,Percent of Total Billed Charges,47% of Total Billed Charges,474.7,47,,62.792,Percent of Total Billed Charges,47% of Total Billed Charges,474.7,2000,
SIM REP LAC F 2.5CM,1510347,CDM,450,RC,12011,HCPCS,Outpatient,,,300.00,300.00,,176.25,58.75,,256.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,176.25,58.75,,256.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.23,48.41,,211.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,3.96,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,21.6,Fee Schedule,100% of ASC Tier Groupings,141,47,,205.296,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,21.6,Fee Schedule,100% of ASC Tier Groupings,176.25,58.75,,256.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,141,47,,205.296,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,141,47,,205.296,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,56.32,115,,131.6,Fee Schedule,115% of CMS OPPS Rate,56.32,115,,131.6,Fee Schedule,115% of CMS OPPS Rate,56.32,191.52,
SIM REP F 2.6-5.0CM,1510349,CDM,450,RC,12013,HCPCS,Outpatient,,,300.00,300.00,,176.25,58.75,,98.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,176.25,58.75,,98.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.23,48.41,,80.944,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,99.504,Fee Schedule,100% of ASC Tier Groupings,141,47,,78.584,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,99.504,Fee Schedule,100% of ASC Tier Groupings,176.25,58.75,,98.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,141,47,,78.584,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,141,47,,78.584,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,58.64,115,,56.872,Fee Schedule,115% of CMS OPPS Rate,58.64,115,,56.872,Fee Schedule,115% of CMS OPPS Rate,58.64,191.52,
S RP LAC F 736-12.5C,1510350,CDM,450,RC,12015,HCPCS,Outpatient,,,203.00,203.00,,119.26,58.75,,119.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,119.26,58.75,,119.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,98.27,48.41,,98.368,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,7.2,Fee Schedule,100% of ASC Tier Groupings,95.41,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,7.2,Fee Schedule,100% of ASC Tier Groupings,119.26,58.75,,119.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.6,100,,,Fee Schedule,100% of ASC Tier Groupings,95.41,47,,95.504,Percent of Total Billed Charges,47% of Total Billed charges,75.6,100,,,Fee Schedule,100% ASC Tier Groupings,95.41,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,95.12,115,,7.504,Fee Schedule,115% of CMS OPPS Rate,95.12,115,,7.504,Fee Schedule,115% of CMS OPPS Rate,75.6,191.52,
S RP LAC F 12.6-20.0,1510351,CDM,450,RC,12016,HCPCS,Outpatient,,,546.00,546.00,,320.78,58.75,,116.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,320.78,58.75,,116.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,264.32,48.41,,96.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,195.84,Fee Schedule,100% of ASC Tier Groupings,256.62,47,,93.248,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,195.84,Fee Schedule,100% of ASC Tier Groupings,320.78,58.75,,116.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,256.62,47,,93.248,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,256.62,47,,93.248,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,128.83,115,,51.288,Fee Schedule,115% of CMS OPPS Rate,128.83,115,,51.288,Fee Schedule,115% of CMS OPPS Rate,128.83,349.44,
S RP LAC F 20.1-30.0,1510352,CDM,450,RC,12017,HCPCS,Outpatient,,,249.00,249.00,,146.29,58.75,,256.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,146.29,58.75,,256.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,120.54,48.41,,211.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,23.04,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,198.72,Fee Schedule,100% of ASC Tier Groupings,117.03,47,,205.296,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,198.72,Fee Schedule,100% of ASC Tier Groupings,146.29,58.75,,256.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,117.03,47,,205.296,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,117.03,47,,205.296,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,155.19,115,,61.416,Fee Schedule,115% of CMS OPPS Rate,155.19,115,,61.416,Fee Schedule,115% of CMS OPPS Rate,117.03,349.44,
SIM RP LAC F >30CM,1510353,CDM,450,RC,12001,HCPCS,Outpatient,,,234.00,234.00,,137.48,58.75,,172.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,137.48,58.75,,172.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,113.28,48.41,,142.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,5.04,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,1.44,Fee Schedule,100% of ASC Tier Groupings,109.98,47,,137.992,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,1.44,Fee Schedule,100% of ASC Tier Groupings,137.48,58.75,,172.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,109.98,47,,137.992,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,109.98,47,,137.992,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.21,115,,15.04,Fee Schedule,115% of CMS OPPS Rate,45.21,115,,15.04,Fee Schedule,115% of CMS OPPS Rate,45.21,191.52,
S RP LAC OTF <2.5CM,1510354,CDM,450,RC,12001,HCPCS,Outpatient,,,300.00,300.00,,176.25,58.75,,177.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,176.25,58.75,,177.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.23,48.41,,146.12,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,4.32,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,3.96,Fee Schedule,100% of ASC Tier Groupings,141,47,,141.864,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,3.96,Fee Schedule,100% of ASC Tier Groupings,176.25,58.75,,177.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,141,47,,141.864,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,141,47,,141.864,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.21,115,,10.528,Fee Schedule,115% of CMS OPPS Rate,45.21,115,,10.528,Fee Schedule,115% of CMS OPPS Rate,45.21,191.52,
S RP LAC OTF 2.6-7.5,1510355,CDM,450,RC,12002,HCPCS,Outpatient,,,300.00,300.00,,176.25,58.75,,181.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,176.25,58.75,,181.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.23,48.41,,149.8,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,5.04,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,141,47,,145.44,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,176.25,58.75,,181.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,141,47,,145.44,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,141,47,,145.44,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,59.43,115,,11.28,Fee Schedule,115% of CMS OPPS Rate,59.43,115,,11.28,Fee Schedule,115% of CMS OPPS Rate,59.43,191.52,
S RP LAC OTF7.6-12.5,1510356,CDM,450,RC,12004,HCPCS,Outpatient,,,300.00,300.00,,176.25,58.75,,211.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,176.25,58.75,,211.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.23,48.41,,174.664,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,141,47,,169.576,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,176.25,58.75,,211.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,141,47,,169.576,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,141,47,,169.576,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,73.99,115,,12.784,Fee Schedule,115% of CMS OPPS Rate,73.99,115,,12.784,Fee Schedule,115% of CMS OPPS Rate,73.99,191.52,
S RP LAC OTF12.6-20.,1510357,CDM,450,RC,12005,HCPCS,Outpatient,,,546.00,546.00,,320.78,58.75,,116.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,320.78,58.75,,116.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,264.32,48.41,,96.104,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,5.04,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,256.62,47,,93.304,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,320.78,58.75,,116.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,256.62,47,,93.304,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,256.62,47,,93.304,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,95.51,115,,9.024,Fee Schedule,115% of CMS OPPS Rate,95.51,115,,9.024,Fee Schedule,115% of CMS OPPS Rate,95.51,349.44,
S RP LAC OTF 20.1-30,1510358,CDM,450,RC,12006,HCPCS,Outpatient,,,209.00,209.00,,122.79,58.75,,149.416,Percent of Total Billed Charges,58.75% of Total Billed Charges,122.79,58.75,,149.416,Percent of Total Billed Charges,58.75% of Total Billed Charges,101.18,48.41,,123.12,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,23.04,Fee Schedule,100% of ASC Tier Groupings,98.23,47,,119.528,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,23.04,Fee Schedule,100% of ASC Tier Groupings,122.79,58.75,,149.416,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,98.23,47,,119.528,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,98.23,47,,119.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,117.73,115,,7.52,Fee Schedule,115% of CMS OPPS Rate,117.73,115,,7.52,Fee Schedule,115% of CMS OPPS Rate,98.23,349.44,
S RP LAC OTF >30CM,1510359,CDM,450,RC,12007,HCPCS,Outpatient,,,254.00,254.00,,149.23,58.75,,143.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,149.23,58.75,,143.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,122.96,48.41,,118.504,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,5.04,Fee Schedule,100% of ASC Tier Groupings,119.38,47,,115.056,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,5.04,Fee Schedule,100% of ASC Tier Groupings,149.23,58.75,,143.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.6,100,,,Fee Schedule,100% of ASC Tier Groupings,119.38,47,,115.056,Percent of Total Billed Charges,47% of Total Billed charges,75.6,100,,,Fee Schedule,100% ASC Tier Groupings,119.38,47,,115.056,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,146.11,115,,15.04,Fee Schedule,115% of CMS OPPS Rate,146.11,115,,15.04,Fee Schedule,115% of CMS OPPS Rate,75.6,191.52,
INT RP TR/EXT<2.5CM,1510362,CDM,450,RC,12031,HCPCS,Outpatient,,,248.00,248.00,,145.7,58.75,,163.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.7,58.75,,163.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,120.06,48.41,,134.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,5.04,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,4.32,Fee Schedule,100% of ASC Tier Groupings,116.56,47,,130.888,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,4.32,Fee Schedule,100% of ASC Tier Groupings,145.7,58.75,,163.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,116.56,47,,130.888,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,116.56,47,,130.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,153.56,115,,16.168,Fee Schedule,115% of CMS OPPS Rate,153.56,115,,16.168,Fee Schedule,115% of CMS OPPS Rate,116.56,349.44,
INT RP TR/EXT2.6-7.5,1510363,CDM,450,RC,12032,HCPCS,Outpatient,,,546.00,546.00,,320.78,58.75,,193.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,320.78,58.75,,193.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,264.32,48.41,,159.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,4.32,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,5.04,Fee Schedule,100% of ASC Tier Groupings,256.62,47,,154.44,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,5.04,Fee Schedule,100% of ASC Tier Groupings,320.78,58.75,,193.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,256.62,47,,154.44,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,256.62,47,,154.44,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,193.37,115,,111.064,Fee Schedule,115% of CMS OPPS Rate,193.37,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,145.5,349.44,
INT RP T/EX7.6-12.5,1510364,CDM,450,RC,12034,HCPCS,Outpatient,,,367.00,367.00,,215.61,58.75,,209.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,215.61,58.75,,209.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,177.66,48.41,,172.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,4.752,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,172.49,47,,167.32,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,215.61,58.75,,209.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,172.49,47,,167.32,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,172.49,47,,167.32,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,208.52,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,208.52,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,145.5,349.44,
INT RP T/EX12.6-20.0,1510365,CDM,450,RC,12035,HCPCS,Outpatient,,,377.30,377.30,,221.66,58.75,,123.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,221.66,58.75,,123.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,182.65,48.41,,102.168,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,5.04,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,5.04,Fee Schedule,100% of ASC Tier Groupings,177.33,47,,99.192,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,5.04,Fee Schedule,100% of ASC Tier Groupings,221.66,58.75,,123.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,177.33,47,,99.192,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,177.33,47,,99.192,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,243.74,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,243.74,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,145.5,349.44,
INT RP T/EX20.1-30.0,1510366,CDM,450,RC,12036,HCPCS,Outpatient,,,386.80,386.80,,227.25,58.75,,179.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,227.25,58.75,,179.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,187.25,48.41,,147.92,Percent of Total Billed Charges,48.41% of Total Billed Charges,543.2,100,,5.04,fee Schedule,100% of ASC Tier Groupings ,543.2,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,181.8,47,,143.608,Percent of Total Billed Charges,47% of Total Billed Charges,543.2,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,227.25,58.75,,179.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,220.47,100,,,Fee Schedule,100% of ASC Tier Groupings,181.8,47,,143.608,Percent of Total Billed Charges,47% of Total Billed charges,220.47,100,,,Fee Schedule,100% ASC Tier Groupings,181.8,47,,143.608,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,284.28,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,284.28,115,,12.032,Fee Schedule,115% of CMS OPPS Rate,181.8,543.2,
INT RP T/EXT >30CM,1510367,CDM,450,RC,12037,HCPCS,Outpatient,,,451.00,451.00,,264.96,58.75,,147.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,264.96,58.75,,147.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,218.33,48.41,,121.176,Percent of Total Billed Charges,48.41% of Total Billed Charges,1774.08,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,1774.08,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,211.97,47,,117.648,Percent of Total Billed Charges,47% of Total Billed Charges,1774.08,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,264.96,58.75,,147.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.01,100,,,Fee Schedule,100% of ASC Tier Groupings,211.97,47,,117.648,Percent of Total Billed Charges,47% of Total Billed charges,721.01,100,,,Fee Schedule,100% ASC Tier Groupings,211.97,47,,117.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,329.19,115,,12.032,Fee Schedule,115% of CMS OPPS Rate,329.19,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,211.97,1774.08,
"INT RP N,H,F<2.5 CM",1510368,CDM,450,RC,12041,HCPCS,Outpatient,,,248.15,248.15,,145.79,58.75,,169.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.79,58.75,,169.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,120.13,48.41,,139.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,5.04,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,5.04,Fee Schedule,100% of ASC Tier Groupings,116.63,47,,135.736,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,5.04,Fee Schedule,100% of ASC Tier Groupings,145.79,58.75,,169.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,116.63,47,,135.736,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,116.63,47,,135.736,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,148.26,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,148.26,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,116.63,349.44,
INT RP NHF 2.6-7.5CM,1510369,CDM,450,RC,12042,HCPCS,Outpatient,,,317.90,317.90,,186.77,58.75,,184.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,186.77,58.75,,184.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,153.9,48.41,,152.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,5.04,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,4.32,Fee Schedule,100% of ASC Tier Groupings,149.41,47,,147.768,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,4.32,Fee Schedule,100% of ASC Tier Groupings,186.77,58.75,,184.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,149.41,47,,147.768,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,149.41,47,,147.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,199.39,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,199.39,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,145.5,349.44,
INT RP NHF7.6-12.5CM,1510370,CDM,450,RC,12044,HCPCS,Outpatient,,,306.00,306.00,,179.78,58.75,,235.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,179.78,58.75,,235.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,148.13,48.41,,193.792,Percent of Total Billed Charges,48.41% of Total Billed Charges,543.2,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,543.2,100,,4.752,Fee Schedule,100% of ASC Tier Groupings,143.82,47,,188.152,Percent of Total Billed Charges,47% of Total Billed Charges,543.2,100,,4.752,Fee Schedule,100% of ASC Tier Groupings,179.78,58.75,,235.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,220.47,100,,,Fee Schedule,100% of ASC Tier Groupings,143.82,47,,188.152,Percent of Total Billed Charges,47% of Total Billed charges,220.47,100,,,Fee Schedule,100% ASC Tier Groupings,143.82,47,,188.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,218.12,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,218.12,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,143.82,543.2,
INT RP NHF 12.6-20.0,1510371,CDM,450,RC,12045,HCPCS,Outpatient,,,348.10,348.10,,204.51,58.75,,326.416,Percent of Total Billed Charges,58.75% of Total Billed Charges,204.51,58.75,,326.416,Percent of Total Billed Charges,58.75% of Total Billed Charges,168.52,48.41,,268.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,543.2,100,,3.96,fee Schedule,100% of ASC Tier Groupings ,543.2,100,,5.04,Fee Schedule,100% of ASC Tier Groupings,163.61,47,,261.136,Percent of Total Billed Charges,47% of Total Billed Charges,543.2,100,,5.04,Fee Schedule,100% of ASC Tier Groupings,204.51,58.75,,326.416,Percent of Total Billed Charges,58.75% of Total Billed Charges,220.47,100,,,Fee Schedule,100% of ASC Tier Groupings,163.61,47,,261.136,Percent of Total Billed Charges,47% of Total Billed charges,220.47,100,,,Fee Schedule,100% ASC Tier Groupings,163.61,47,,261.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,274.41,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,274.41,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,163.61,543.2,
INT RP NHF 20.1-30.0,1510372,CDM,450,RC,12046,HCPCS,Outpatient,,,410.75,410.75,,241.32,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,241.32,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,198.84,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,14.4,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,5.04,Fee Schedule,100% of ASC Tier Groupings,193.05,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,5.04,Fee Schedule,100% of ASC Tier Groupings,241.32,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,220.47,100,,,Fee Schedule,100% of ASC Tier Groupings,193.05,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,220.47,100,,,Fee Schedule,100% ASC Tier Groupings,193.05,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,316.78,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,316.78,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,193.05,349.44,
INT RP NHF > 30CM,1510373,CDM,450,RC,12047,HCPCS,Outpatient,,,445.00,445.00,,261.44,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,261.44,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,215.42,48.41,,6.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,1774.08,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,1774.08,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,209.15,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,1774.08,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,261.44,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.01,100,,,Fee Schedule,100% of ASC Tier Groupings,209.15,47,,6.768,Percent of Total Billed Charges,47% of Total Billed charges,721.01,100,,,Fee Schedule,100% ASC Tier Groupings,209.15,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,351.41,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,351.41,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,209.15,1774.08,
INT RP FACE < 2.5 CM,1510374,CDM,450,RC,12051,HCPCS,Outpatient,,,263.80,263.80,,154.98,58.75,,79.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,154.98,58.75,,79.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,127.71,48.41,,65.448,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,15.84,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,5.04,Fee Schedule,100% of ASC Tier Groupings,123.99,47,,63.544,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,5.04,Fee Schedule,100% of ASC Tier Groupings,154.98,58.75,,79.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,123.99,47,,63.544,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,123.99,47,,63.544,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,171.59,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,171.59,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,123.99,349.44,
INT RP FACE 2.6-5.0,1510375,CDM,450,RC,12052,HCPCS,Outpatient,,,381.94,381.94,,224.39,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,224.39,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,184.9,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,5.04,Fee Schedule,100% of ASC Tier Groupings,179.51,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,5.04,Fee Schedule,100% of ASC Tier Groupings,224.39,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,179.51,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,179.51,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,203.07,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,203.07,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,145.5,349.44,
INT RP FACE 5.1-7.5,1510376,CDM,450,RC,12053,HCPCS,Outpatient,,,312.90,312.90,,183.83,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,183.83,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,151.47,48.41,,63.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,147.06,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,183.83,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,147.06,47,,62.04,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,147.06,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,219.16,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,219.16,115,,2.48,Fee Schedule,115% of CMS OPPS Rate,145.5,349.44,
INT RP FACE 7.6-12.5,1510378,CDM,450,RC,12054,HCPCS,Outpatient,,,361.00,361.00,,212.09,58.75,,9.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,212.09,58.75,,9.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,174.76,48.41,,7.672,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,5.04,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,3.96,Fee Schedule,100% of ASC Tier Groupings,169.67,47,,7.448,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,3.96,Fee Schedule,100% of ASC Tier Groupings,212.09,58.75,,9.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,169.67,47,,7.448,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,169.67,47,,7.448,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,223.84,115,,2.48,Fee Schedule,115% of CMS OPPS Rate,223.84,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,145.5,349.44,
INT RP F 12.6-20.0CM,1510379,CDM,450,RC,12055,HCPCS,Outpatient,,,393.00,393.00,,230.89,58.75,,26.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,230.89,58.75,,26.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,190.25,48.41,,22.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,1.44,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,14.4,Fee Schedule,100% of ASC Tier Groupings,184.71,47,,21.504,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,14.4,Fee Schedule,100% of ASC Tier Groupings,230.89,58.75,,26.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,184.71,47,,21.504,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,184.71,47,,21.504,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,303.8,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,303.8,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,145.5,349.44,
INT RP FACE 20.1-30.,1510380,CDM,450,RC,12056,HCPCS,Outpatient,,,500.40,500.40,,293.99,58.75,,104.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,293.99,58.75,,104.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,242.24,48.41,,86.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,6.48,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,235.19,47,,83.848,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,293.99,58.75,,104.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,235.19,47,,83.848,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,235.19,47,,83.848,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,387.5,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,387.5,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,145.5,387.5,
COLONOSCOPY,1510392,CDM,360,RC,45378,HCPCS,Outpatient,,,694.50,694.50,,408.02,58.75,,163.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,408.02,58.75,,163.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,336.21,48.41,,134.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,835.52,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,835.52,100,,15.84,Fee Schedule,100% of ASC Tier Groupings,326.42,47,,130.512,Percent of Total Billed Charges,47% of Total Billed Charges,835.52,100,,15.84,Fee Schedule,100% of ASC Tier Groupings,408.02,58.75,,163.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,334.06,100,,,Fee Schedule,100% of ASC Tier Groupings,326.42,47,,130.512,Percent of Total Billed Charges,47% of Total Billed charges,334.06,100,,,Fee Schedule,100% ASC Tier Groupings,326.42,47,,130.512,Percent of Total Billed Charges,47% of Total Billed Charges,620,100,,,Fee Schedule,100% of ASC Tier Groupings,186.81,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,186.81,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,186.81,835.52,
RECOV RM EA ADD15M,1510406,CDM,710,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,51.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,51.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,42.6,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,41.36,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,51.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,41.36,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,41.36,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
OP BED PER HOUR,1510407,CDM,710,RC,,,Outpatient,,,18.00,18.00,,10.58,58.75,,31.936,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.58,58.75,,31.936,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.71,48.41,,26.312,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.2,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,8.46,47,,25.552,Percent of Total Billed Charges,47% of Total Billed Charges,16.2,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,10.58,58.75,,31.936,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,25.552,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.46,47,,25.552,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,16.2,
EPIDURAL,1510409,CDM,370,RC,,,Outpatient,,,169.00,169.00,,99.29,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,99.29,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,81.81,48.41,,8.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,152.1,90,,29.52,Percent of Total Billed Charges,90% of Total Billed Charges,152.1,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,79.43,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,152.1,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,99.29,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,79.43,47,,8.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,79.43,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,79.43,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,79.43,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,79.43,152.1,
SPINAL PER MIN,1510410,CDM,270,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,38.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,38.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,31.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,30.416,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,38.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,30.416,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,30.416,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
SURGICAL PHOTO EACH,1510412,CDM,360,RC,,,Outpatient,,,165.00,165.00,,96.94,58.75,,30.176,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.94,58.75,,30.176,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.88,48.41,,24.864,Percent of Total Billed Charges,48.41% of Total Billed Charges,148.5,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,148.5,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,77.55,47,,24.136,Percent of Total Billed Charges,47% of Total Billed Charges,148.5,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,96.94,58.75,,30.176,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.55,47,,24.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,77.55,47,,24.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.55,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,77.55,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,77.55,148.5,
PRE-OP BED PER HOUR,1510420,CDM,710,RC,,,Outpatient,,,19.80,19.80,,11.63,58.75,,183.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.63,58.75,,183.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.59,48.41,,151.384,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.82,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,17.82,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,9.31,47,,146.976,Percent of Total Billed Charges,47% of Total Billed Charges,17.82,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,11.63,58.75,,183.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.31,47,,146.976,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.31,47,,146.976,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.31,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,9.31,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,9.31,17.82,
DISP SNARE COLON/EGD,1510424,CDM,270,RC,,,Outpatient,,,57.20,57.20,,33.61,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.61,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.69,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,51.48,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,51.48,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,26.88,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,51.48,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,33.61,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.88,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.88,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.88,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,26.88,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,26.88,51.48,
EXCISION LESION3 CM,1510426,CDM,450,RC,11423,HCPCS,Outpatient,,,223.00,223.00,,131.01,58.75,,109.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,131.01,58.75,,109.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,107.95,48.41,,89.848,Percent of Total Billed Charges,48.41% of Total Billed Charges,1500.8,100,,71.28,fee Schedule,100% of ASC Tier Groupings ,1500.8,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,104.81,47,,87.232,Percent of Total Billed Charges,47% of Total Billed Charges,1500.8,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,131.01,58.75,,109.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,102.96,100,,,Fee Schedule,100% of ASC Tier Groupings,104.81,47,,87.232,Percent of Total Billed Charges,47% of Total Billed charges,102.96,100,,,Fee Schedule,100% ASC Tier Groupings,104.81,47,,87.232,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,161.03,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,161.03,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,102.96,1500.8,
VASECTOMY,1510427,CDM,360,RC,55250,HCPCS,Outpatient,,,347.10,347.10,,203.92,58.75,,251.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,203.92,58.75,,251.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,168.03,48.41,,207.192,Percent of Total Billed Charges,48.41% of Total Billed Charges,1936.48,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,1936.48,100,,29.52,Fee Schedule,100% of ASC Tier Groupings,163.14,47,,201.16,Percent of Total Billed Charges,47% of Total Billed Charges,1936.48,100,,29.52,Fee Schedule,100% of ASC Tier Groupings,203.92,58.75,,251.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,641.85,100,,,Fee Schedule,100% of ASC Tier Groupings,163.14,47,,201.16,Percent of Total Billed Charges,47% of Total Billed charges,641.85,100,,,Fee Schedule,100% ASC Tier Groupings,163.14,47,,201.16,Percent of Total Billed Charges,47% of Total Billed Charges,1029,100,,,Fee Schedule,100% of ASC Tier Groupings,236.07,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,236.07,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,163.14,1936.48,
CRYOSURGICAL LES FAC,1510428,CDM,360,RC,17110,HCPCS,Outpatient,,,110.00,110.00,,64.63,58.75,,292.456,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.63,58.75,,292.456,Percent of Total Billed Charges,58.75% of Total Billed Charges,53.25,48.41,,240.984,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,3.96,Fee Schedule,100% of ASC Tier Groupings,51.7,47,,233.968,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,3.96,Fee Schedule,100% of ASC Tier Groupings,64.63,58.75,,292.456,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,51.7,47,,233.968,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,51.7,47,,233.968,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,69.74,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,69.74,115,,0.752,Fee Schedule,115% of CMS OPPS Rate,51.7,462,
DEBRIDE/NAIL 6+,1510429,CDM,360,RC,11721,HCPCS,Outpatient,,,67.95,67.95,,39.92,58.75,,87.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.92,58.75,,87.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.89,48.41,,71.992,Percent of Total Billed Charges,48.41% of Total Billed Charges,60.48,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,60.48,100,,23.04,Fee Schedule,100% of ASC Tier Groupings,31.94,47,,69.896,Percent of Total Billed Charges,47% of Total Billed Charges,60.48,100,,23.04,Fee Schedule,100% of ASC Tier Groupings,39.92,58.75,,87.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.94,47,,69.896,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.94,47,,69.896,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,25.01,115,,0.752,Fee Schedule,115% of CMS OPPS Rate,25.01,115,,3.384,Fee Schedule,115% of CMS OPPS Rate,25.01,462,
DEBRIDE NAIL 1-5,1510430,CDM,360,RC,11720,HCPCS,Outpatient,,,23.00,23.00,,13.51,58.75,,83.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.51,58.75,,83.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.13,48.41,,68.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,60.48,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,60.48,100,,41.04,Fee Schedule,100% of ASC Tier Groupings,10.81,47,,66.744,Percent of Total Billed Charges,47% of Total Billed Charges,60.48,100,,41.04,Fee Schedule,100% of ASC Tier Groupings,13.51,58.75,,83.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,66.744,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.81,47,,66.744,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,15.03,115,,3.384,Fee Schedule,115% of CMS OPPS Rate,15.03,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,10.81,462,
CRYOSURGERY LESION,1510431,CDM,360,RC,17000,HCPCS,Outpatient,,,80.90,80.90,,47.53,58.75,,10.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.53,58.75,,10.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.16,48.41,,8.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,20.16,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,5.04,Fee Schedule,100% of ASC Tier Groupings,38.02,47,,8.608,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,5.04,Fee Schedule,100% of ASC Tier Groupings,47.53,58.75,,10.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.02,47,,8.608,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,38.02,47,,8.608,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,55.64,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,55.64,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,38.02,462,
SKIN LESION OF CHEEK,1510432,CDM,360,RC,11311,HCPCS,Outpatient,,,64.20,64.20,,37.72,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.72,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.08,48.41,,12.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,12.24,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,71.28,Fee Schedule,100% of ASC Tier Groupings,30.17,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,71.28,Fee Schedule,100% of ASC Tier Groupings,37.72,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.6,100,,,Fee Schedule,100% of ASC Tier Groupings,30.17,47,,12.408,Percent of Total Billed Charges,47% of Total Billed charges,75.6,100,,,Fee Schedule,100% ASC Tier Groupings,30.17,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,64.22,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,64.22,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.17,462,
EXCISION EXTERNAL HEMORRHOID,1510434,CDM,360,RC,46230,HCPCS,Outpatient,,,390.89,390.89,,229.65,58.75,,6.256,Percent of Total Billed Charges,58.75% of Total Billed Charges,229.65,58.75,,6.256,Percent of Total Billed Charges,58.75% of Total Billed Charges,189.23,48.41,,5.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,2561.44,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,2561.44,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,183.72,47,,5.008,Percent of Total Billed Charges,47% of Total Billed Charges,2561.44,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,229.65,58.75,,6.256,Percent of Total Billed Charges,58.75% of Total Billed Charges,955.83,100,,,Fee Schedule,100% of ASC Tier Groupings,183.72,47,,5.008,Percent of Total Billed Charges,47% of Total Billed charges,955.83,100,,,Fee Schedule,100% ASC Tier Groupings,183.72,47,,5.008,Percent of Total Billed Charges,47% of Total Billed Charges,620,100,,,Fee Schedule,100% of ASC Tier Groupings,176.64,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,176.64,115,,15.416,Fee Schedule,115% of CMS OPPS Rate,176.64,2561.44,
MULTI TRAUMA DRSNG,1520022,CDM,270,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,11.232,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,10.904,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,15.416,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
I&D BARTH GL ABSCESS,1520043,CDM,450,RC,56420,HCPCS,Outpatient,,,232.00,232.00,,136.3,58.75,,8.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,136.3,58.75,,8.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,112.31,48.41,,6.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,181.44,100,,5.04,fee Schedule,100% of ASC Tier Groupings ,181.44,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,109.04,47,,6.52,Percent of Total Billed Charges,47% of Total Billed Charges,181.44,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,136.3,58.75,,8.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,71.72,100,,,Fee Schedule,100% of ASC Tier Groupings,109.04,47,,6.52,Percent of Total Billed Charges,47% of Total Billed charges,71.72,100,,,Fee Schedule,100% ASC Tier Groupings,109.04,47,,6.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,110.65,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,110.65,115,,12.032,Fee Schedule,115% of CMS OPPS Rate,71.72,181.44,
EGD W BIOPSY SIN/MUL,1520044,CDM,360,RC,43239,HCPCS,Outpatient,,,535.00,535.00,,314.31,58.75,,203.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,314.31,58.75,,203.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,258.99,48.41,,167.696,Percent of Total Billed Charges,48.41% of Total Billed Charges,859.04,100,,4.32,fee Schedule,100% of ASC Tier Groupings ,859.04,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,251.45,47,,162.808,Percent of Total Billed Charges,47% of Total Billed Charges,859.04,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,314.31,58.75,,203.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,340.62,100,,,Fee Schedule,100% of ASC Tier Groupings,251.45,47,,162.808,Percent of Total Billed Charges,47% of Total Billed charges,340.62,100,,,Fee Schedule,100% ASC Tier Groupings,251.45,47,,162.808,Percent of Total Billed Charges,47% of Total Billed Charges,620,100,,,Fee Schedule,100% of ASC Tier Groupings,139.91,115,,12.032,Fee Schedule,115% of CMS OPPS Rate,139.91,115,,21.432,Fee Schedule,115% of CMS OPPS Rate,139.91,859.04,
RP CXP ENEL 2.6-7.5,1520055,CDM,450,RC,13152,HCPCS,Outpatient,,,622.25,622.25,,365.57,58.75,,40.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,365.57,58.75,,40.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,301.23,48.41,,33.696,Percent of Total Billed Charges,48.41% of Total Billed Charges,543.2,100,,5.04,fee Schedule,100% of ASC Tier Groupings ,543.2,100,,20.16,Fee Schedule,100% of ASC Tier Groupings,292.46,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,543.2,100,,20.16,Fee Schedule,100% of ASC Tier Groupings,365.57,58.75,,40.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,220.47,100,,,Fee Schedule,100% of ASC Tier Groupings,292.46,47,,32.712,Percent of Total Billed Charges,47% of Total Billed charges,220.47,100,,,Fee Schedule,100% ASC Tier Groupings,292.46,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,340.53,115,,21.432,Fee Schedule,115% of CMS OPPS Rate,340.53,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,220.47,543.2,
CARDIAC MONITOR,1520058,CDM,730,RC,93041,HCPCS,Outpatient,,,185.90,185.90,,109.22,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,109.22,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.99,48.41,,31.76,Percent of Total Billed Charges,48.41% of Total Billed Charges,52.81,100,,7.92,fee Schedule,100% of BCBS fee schedule,52.81,100,,12.24,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,87.37,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,52.81,100,,12.24,Fee Schedule,100% of BCBS PPO fee schedule,109.22,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,87.37,47,,30.832,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,87.37,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,6.27,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,6.27,115,,37.224,Fee Schedule,115% of CMS OPPS Rate,6.27,109.22,
EXCISION OF CYST,1520061,CDM,360,RC,11402,HCPCS,Outpatient,,,177.50,177.50,,104.28,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,104.28,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,85.93,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,667.52,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,667.52,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,83.43,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,667.52,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,104.28,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,95.31,100,,,Fee Schedule,100% of ASC Tier Groupings,83.43,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,95.31,100,,,Fee Schedule,100% ASC Tier Groupings,83.43,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,475,100,,,Fee Schedule,100% of ASC Tier Groupings,117.54,115,,37.224,Fee Schedule,115% of CMS OPPS Rate,117.54,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,83.43,667.52,
HEATED AEROSOL P/HR,2010001,CDM,410,RC,94640,HCPCS,Outpatient,,,22.90,22.90,,13.45,58.75,,5.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.45,58.75,,5.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.09,48.41,,4.216,Percent of Total Billed Charges,48.41% of Total Billed Charges,176.61,100,,3.6,fee Schedule,100% of BCBS fee schedule,176.61,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,10.76,47,,4.096,Percent of Total Billed Charges,47% of Total Billed Charges,176.61,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,13.45,58.75,,5.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.76,47,,4.096,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.76,47,,4.096,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,7.54,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,7.54,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,7.54,176.61,
HEATED AEROSOL TREAT,2010003,CDM,410,RC,94640,HCPCS,Outpatient,,,33.00,33.00,,19.39,58.75,,16.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.39,58.75,,16.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.98,48.41,,13.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,176.61,100,,30.96,fee Schedule,100% of BCBS fee schedule,176.61,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,15.51,47,,13.192,Percent of Total Billed Charges,47% of Total Billed Charges,176.61,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,19.39,58.75,,16.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,13.192,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.51,47,,13.192,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,7.54,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,7.54,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,7.54,176.61,
ABG KIT,2010004,CDM,270,RC,,,Outpatient,,,13.31,13.31,,7.82,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.82,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.44,48.41,,14.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.98,90,,7.128,Percent of Total Billed Charges,90% of Total Billed Charges,11.98,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,6.26,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,11.98,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,7.82,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.26,47,,14.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.26,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.26,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.26,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.26,11.98,
AMBULATE W/OXYGEN/TR,2010005,CDM,460,RC,94680,HCPCS,Outpatient,,,29.00,29.00,,17.04,58.75,,32.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.04,58.75,,32.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.04,48.41,,27.112,Percent of Total Billed Charges,48.41% of Total Billed Charges,132.82,100,,5.04,fee Schedule,100% of BCBS fee schedule,132.82,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,13.63,47,,26.32,Percent of Total Billed Charges,47% of Total Billed Charges,132.82,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,17.04,58.75,,32.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.63,47,,26.32,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.63,47,,26.32,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,33.35,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,33.35,115,,10.528,Fee Schedule,115% of CMS OPPS Rate,13.63,132.82,
CANNULE DISPOS,2010039,CDM,270,RC,,,Outpatient,,,17.33,17.33,,10.18,58.75,,140.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.18,58.75,,140.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.39,48.41,,115.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.6,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,15.6,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,8.15,47,,112.048,Percent of Total Billed Charges,47% of Total Billed Charges,15.6,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,10.18,58.75,,140.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.15,47,,112.048,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.15,47,,112.048,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.15,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,8.15,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,8.15,15.6,
CPR,2010043,CDM,410,RC,92950,HCPCS,Outpatient,,,433.00,433.00,,254.39,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,254.39,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,209.62,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,276.64,100,,3.6,fee Schedule,100% of BCBS fee schedule,276.64,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,203.51,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,276.64,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,254.39,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,203.51,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,203.51,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,189.45,115,,6.392,Fee Schedule,115% of CMS OPPS Rate,189.45,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,90,276.64,
02 AEROSOL TENTDAIL,2010062,CDM,460,RC,94640,HCPCS,Outpatient,,,87.00,87.00,,51.11,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.11,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.12,48.41,,9.296,Percent of Total Billed Charges,48.41% of Total Billed Charges,176.61,100,,5.76,fee Schedule,100% of BCBS fee schedule,176.61,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,40.89,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,176.61,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,51.11,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.89,47,,9.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.89,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,7.54,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,7.54,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,7.54,176.61,
INC SPIR TREATMENT,2010067,CDM,460,RC,94010,HCPCS,Outpatient,,,82.00,82.00,,48.18,58.75,,30.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.18,58.75,,30.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.7,48.41,,25.176,Percent of Total Billed Charges,48.41% of Total Billed Charges,132.82,100,,5.76,fee Schedule,100% of BCBS fee schedule,132.82,100,,30.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,38.54,47,,24.44,Percent of Total Billed Charges,47% of Total Billed Charges,132.82,100,,30.96,Fee Schedule,100% of BCBS PPO fee schedule,48.18,58.75,,30.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.54,47,,24.44,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,38.54,47,,24.44,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,26.85,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,26.85,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,26.85,132.82,
NEBULIZER,2010078,CDM,270,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,164.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,164.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,135.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,7.128,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,131.6,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,7.128,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,164.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,131.6,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,131.6,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
SPUTUM COLL CUP,2010082,CDM,270,RC,,,Outpatient,,,10.89,10.89,,6.4,58.75,,8.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.4,58.75,,8.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.27,48.41,,7.376,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,9.8,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,5.12,47,,7.16,Percent of Total Billed Charges,47% of Total Billed Charges,9.8,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.4,58.75,,8.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.12,47,,7.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.12,47,,7.16,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.12,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,5.12,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,5.12,9.8,
ENDO TUBE,2010085,CDM,270,RC,,,Outpatient,,,35.09,35.09,,20.62,58.75,,8.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.62,58.75,,8.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.99,48.41,,7.064,Percent of Total Billed Charges,48.41% of Total Billed Charges,31.58,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,31.58,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,16.49,47,,6.864,Percent of Total Billed Charges,47% of Total Billed Charges,31.58,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,20.62,58.75,,8.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.49,47,,6.864,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.49,47,,6.864,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.49,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,16.49,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,16.49,31.58,
INC SPIR SET UP,2010086,CDM,270,RC,,,Outpatient,,,38.00,38.00,,22.33,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.33,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.4,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,34.2,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,34.2,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,34.2,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,22.33,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.86,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,34.2,
O2 AEROSOL TENTSETU,2010087,CDM,270,RC,,,Outpatient,,,70.00,70.00,,41.13,58.75,,27.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.13,58.75,,27.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.89,48.41,,22.576,Percent of Total Billed Charges,48.41% of Total Billed Charges,63,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,63,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,32.9,47,,21.92,Percent of Total Billed Charges,47% of Total Billed Charges,63,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,41.13,58.75,,27.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.9,47,,21.92,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,32.9,47,,21.92,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.9,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,32.9,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,32.9,63,
02 HUMIDIFIER DISP,2010089,CDM,410,RC,94640,HCPCS,Outpatient,,,298.00,298.00,,175.08,58.75,,103.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,175.08,58.75,,103.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,144.26,48.41,,85.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,176.61,100,,5.04,fee Schedule,100% of BCBS fee schedule,176.61,100,,5.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,140.06,47,,82.704,Percent of Total Billed Charges,47% of Total Billed Charges,176.61,100,,5.76,Fee Schedule,100% of BCBS PPO fee schedule,175.08,58.75,,103.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,140.06,47,,82.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,140.06,47,,82.704,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,7.54,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,7.54,115,,16.168,Fee Schedule,115% of CMS OPPS Rate,7.54,176.61,
SIMPLE O2 MASK,2010090,CDM,270,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,16.168,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,3.72,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
AEROSOL TUBING DISP,2010095,CDM,270,RC,94640,HCPCS,Outpatient,,,24.00,24.00,,14.1,58.75,,5.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.1,58.75,,5.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.62,48.41,,4.224,Percent of Total Billed Charges,48.41% of Total Billed Charges,176.61,100,,3.6,fee Schedule,100% of BCBS fee schedule,176.61,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,11.28,47,,4.096,Percent of Total Billed Charges,47% of Total Billed Charges,176.61,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,14.1,58.75,,5.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,4.096,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.28,47,,4.096,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.54,115,,3.72,Fee Schedule,115% of CMS OPPS Rate,7.54,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,7.54,176.61,
OXYGEN SETUP,2010098,CDM,270,RC,,,Outpatient,,,65.00,65.00,,38.19,58.75,,140.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.19,58.75,,140.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.47,48.41,,115.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,58.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,58.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,30.55,47,,112.048,Percent of Total Billed Charges,47% of Total Billed Charges,58.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,38.19,58.75,,140.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.55,47,,112.048,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,30.55,47,,112.048,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.55,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,30.55,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,30.55,58.5,
INTUBATION,2010099,CDM,460,RC,31500,HCPCS,Outpatient,,,350.00,350.00,,205.63,58.75,,16.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,205.63,58.75,,16.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,169.44,48.41,,13.632,Percent of Total Billed Charges,48.41% of Total Billed Charges,222.88,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,222.88,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,164.5,47,,13.232,Percent of Total Billed Charges,47% of Total Billed Charges,222.88,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,205.63,58.75,,16.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.05,100,,,Fee Schedule,100% of ASC Tier Groupings,164.5,47,,13.232,Percent of Total Billed Charges,47% of Total Billed charges,89.05,100,,,Fee Schedule,100% ASC Tier Groupings,164.5,47,,13.232,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,144.96,115,,10.528,Fee Schedule,115% of CMS OPPS Rate,144.96,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,89.05,222.88,
MASK-CODE,2010101,CDM,270,RC,,,Outpatient,,,19.05,19.05,,11.19,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.19,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.22,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.15,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,17.15,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,8.95,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,17.15,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,11.19,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.95,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.95,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.95,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.95,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,8.95,17.15,
MASK VENTI DISP,2010105,CDM,270,RC,,,Outpatient,,,18.25,18.25,,10.72,58.75,,192.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.72,58.75,,192.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.83,48.41,,158.4,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.43,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,16.43,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,8.58,47,,153.784,Percent of Total Billed Charges,47% of Total Billed Charges,16.43,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,10.72,58.75,,192.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.58,47,,153.784,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.58,47,,153.784,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.58,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,8.58,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,8.58,16.43,
MUCOUS SPEC TRAP,2010106,CDM,270,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,105.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,105.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,86.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,84.224,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,105.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,84.224,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,84.224,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
OXYGEN EMERG RM,2010114,CDM,270,RC,,,Outpatient,,,58.30,58.30,,34.25,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.25,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.22,48.41,,19.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,52.47,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,52.47,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,27.4,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,52.47,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,34.25,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.4,47,,19.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,27.4,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.4,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,27.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,27.4,52.47,
ARTERIAL BLOOD GASES,2010115,CDM,300,RC,82803,HCPCS,Outpatient,,,219.95,219.95,,129.22,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,129.22,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,106.48,48.41,,8.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,26.72,100,,3.6,fee Schedule,100% of BCBS fee schedule,26.72,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,103.38,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,26.72,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,129.22,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,103.38,47,,8.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,103.38,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,21.11,90,,,Fee Schedule,90% of UHC fee schedule,103.38,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,103.38,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,21.11,129.22,
OXYGEN EACH HOUR,2010118,CDM,270,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,28.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,28.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,23.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,28.08,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,23.032,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,28.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,23.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,23.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
AEROSOL MASK,2010123,CDM,270,RC,,,Outpatient,,,10.90,10.90,,6.4,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.4,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.28,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.81,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,9.81,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,5.12,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,9.81,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,6.4,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.12,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.12,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.12,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.12,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,5.12,9.81,
UPDRAFT TREAT,2010124,CDM,410,RC,94640,HCPCS,Outpatient,,,298.00,298.00,,175.08,58.75,,15.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,175.08,58.75,,15.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,144.26,48.41,,13.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,176.61,100,,3.6,fee Schedule,100% of BCBS fee schedule,176.61,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,140.06,47,,12.656,Percent of Total Billed Charges,47% of Total Billed Charges,176.61,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,175.08,58.75,,15.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,140.06,47,,12.656,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,140.06,47,,12.656,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,7.54,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,7.54,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,7.54,176.61,
CPT PERCUSSION P/TX,2010126,CDM,410,RC,94667,HCPCS,Outpatient,,,35.20,35.20,,20.68,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.68,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.04,48.41,,11.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,104.67,100,,3.6,fee Schedule,100% of BCBS fee schedule,104.67,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,16.54,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,104.67,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,20.68,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.54,47,,11.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.54,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,24.06,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,24.06,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,16.54,104.67,
CPT POST DRAIN P/TX,2010129,CDM,410,RC,94667,HCPCS,Outpatient,,,32.00,32.00,,18.8,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,58.864,Percent of Total Billed Charges,48.41% of Total Billed Charges,104.67,100,,41.76,fee Schedule,100% of BCBS fee schedule,104.67,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,15.04,47,,57.152,Percent of Total Billed Charges,47% of Total Billed Charges,104.67,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,18.8,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,57.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,57.152,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,24.06,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,24.06,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,15.04,104.67,
PFT PRE & POST STUDY,2010149,CDM,460,RC,94060,HCPCS,Outpatient,,,409.00,409.00,,240.29,58.75,,11.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,240.29,58.75,,11.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,198,48.41,,9.8,Percent of Total Billed Charges,48.41% of Total Billed Charges,242.98,100,,3.6,fee Schedule,100% of BCBS fee schedule,242.98,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,192.23,47,,9.512,Percent of Total Billed Charges,47% of Total Billed Charges,242.98,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,240.29,58.75,,11.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,192.23,47,,9.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,192.23,47,,9.512,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,38.32,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,38.32,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,38.32,242.98,
PFT PRE STUDY,2010150,CDM,460,RC,94150,HCPCS,Outpatient,,,224.00,224.00,,131.6,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,131.6,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,108.44,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,132.82,100,,3.6,fee Schedule,100% of BCBS fee schedule,132.82,100,,28.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,105.28,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,132.82,100,,28.08,Fee Schedule,100% of BCBS PPO fee schedule,131.6,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,105.28,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,105.28,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,24.41,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,24.41,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,24.41,132.82,
PULSE OXIMETER SETUP,2010151,CDM,460,RC,94760,HCPCS,Outpatient,,,51.00,51.00,,29.96,58.75,,6.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.96,58.75,,6.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.69,48.41,,5.536,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.13,100,,11.52,fee Schedule,100% of BCBS fee schedule,2.13,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,23.97,47,,5.376,Percent of Total Billed Charges,47% of Total Billed Charges,2.13,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,29.96,58.75,,6.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,5.376,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.97,47,,5.376,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,3.38,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,3.38,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,2.13,90,
UPDRAFT SET UP,2010153,CDM,270,RC,,,Outpatient,,,22.99,22.99,,13.51,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.51,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.13,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.69,90,,85.68,Percent of Total Billed Charges,90% of Total Billed Charges,20.69,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,10.81,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,20.69,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,13.51,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.81,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,20.69,
SPUTUM COLLECTION,2010158,CDM,300,RC,89220,HCPCS,Outpatient,,,61.25,61.25,,35.98,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.98,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.65,48.41,,11.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,130.55,100,,4.32,fee Schedule,100% of BCBS fee schedule,130.55,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,28.79,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,130.55,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,35.98,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.79,47,,11.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.79,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,123.38,90,,,Fee Schedule,90% of UHC fee schedule,18.1,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,18.1,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,18.1,130.55,
SPUTUM INDUCTION,2010159,CDM,410,RC,89220,HCPCS,Outpatient,,,22.00,22.00,,12.93,58.75,,54.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,54.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,45.312,Percent of Total Billed Charges,48.41% of Total Billed Charges,130.55,100,,8.64,fee Schedule,100% of BCBS fee schedule,130.55,100,,41.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,10.34,47,,43.992,Percent of Total Billed Charges,47% of Total Billed Charges,130.55,100,,41.76,Fee Schedule,100% of BCBS PPO fee schedule,12.93,58.75,,54.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,43.992,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,43.992,Percent of Total Billed Charges,47% of Total Billed Charges,213.38,100,,,Case Rate,Pays based on per visit rate,18.1,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,18.1,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,10.34,213.38,
SUC REGULATOR P/DAY,2010176,CDM,270,RC,,,Outpatient,,,33.65,33.65,,19.77,58.75,,30.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.77,58.75,,30.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.29,48.41,,25.176,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.29,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,30.29,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,15.82,47,,24.44,Percent of Total Billed Charges,47% of Total Billed Charges,30.29,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,19.77,58.75,,30.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.82,47,,24.44,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.82,47,,24.44,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,15.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,15.82,30.29,
VENTILATOR HRLY,2010187,CDM,410,RC,,,Outpatient,,,30.00,30.00,,17.63,58.75,,40.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.63,58.75,,40.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.52,48.41,,33.272,Percent of Total Billed Charges,48.41% of Total Billed Charges,27,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,27,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,47,,32.304,Percent of Total Billed Charges,47% of Total Billed Charges,27,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,17.63,58.75,,40.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,32.304,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.1,47,,32.304,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,14.1,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,47,,14.664,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,90,
VENTILATOR INITIAL,2010190,CDM,410,RC,94002,HCPCS,Outpatient,,,152.00,152.00,,89.3,58.75,,12.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.3,58.75,,12.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.58,48.41,,10.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,445.96,100,,3.6,fee Schedule,100% of BCBS fee schedule,445.96,100,,11.52,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,71.44,47,,10.344,Percent of Total Billed Charges,47% of Total Billed Charges,445.96,100,,11.52,Fee Schedule,100% of BCBS PPO fee schedule,89.3,58.75,,12.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,71.44,47,,10.344,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,71.44,47,,10.344,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,95.34,115,,14.664,Fee Schedule,115% of CMS OPPS Rate,95.34,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,71.44,445.96,
SUCTION SET-UP,2010193,CDM,270,RC,,,Outpatient,,,25.30,25.30,,14.86,58.75,,3.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.86,58.75,,3.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.25,48.41,,2.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.77,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,22.77,90,,85.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.89,47,,2.48,Percent of Total Billed Charges,47% of Total Billed Charges,22.77,90,,85.68,Percent of Total Billed Charges,90% of Total Billed Charges,14.86,58.75,,3.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.89,47,,2.48,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.89,47,,2.48,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.89,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,11.89,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,11.89,22.77,
TRACH MASK,2010194,CDM,270,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,3.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,3.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,2.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,2.48,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,3.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,2.48,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,2.48,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
NON REBREATHER MASK,2010195,CDM,270,RC,,,Outpatient,,,14.30,14.30,,8.4,58.75,,25.848,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.4,58.75,,25.848,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.92,48.41,,21.304,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.87,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,12.87,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,6.72,47,,20.68,Percent of Total Billed Charges,47% of Total Billed Charges,12.87,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,8.4,58.75,,25.848,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.72,47,,20.68,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.72,47,,20.68,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.72,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.72,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,6.72,12.87,
CONNECTING TUBING,2010196,CDM,270,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,31.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,31.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,25.944,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,25.192,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,31.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,25.192,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,25.192,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
AFTER HR. VENTILATOR,2010197,CDM,410,RC,,,Outpatient,,,30.00,30.00,,17.63,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.63,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.52,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,27,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,27,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,27,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,17.63,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.1,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,14.1,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,90,
SUCTION CANIST/DISP,2010207,CDM,270,RC,,,Outpatient,,,117.00,117.00,,68.74,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,68.74,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,56.64,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,105.3,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,105.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,54.99,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,105.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,68.74,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,54.99,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,54.99,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,54.99,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,54.99,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,54.99,105.3,
RT AMB TRANSFER,2010208,CDM,460,RC,,,Outpatient,,,65.00,65.00,,38.19,58.75,,7.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.19,58.75,,7.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.47,48.41,,6.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,58.5,90,,38.16,Percent of Total Billed Charges,90% of Total Billed Charges,58.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,30.55,47,,5.92,Percent of Total Billed Charges,47% of Total Billed Charges,58.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,38.19,58.75,,7.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.55,47,,5.92,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,30.55,47,,5.92,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,30.55,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,30.55,47,,44.744,Percent of Total Billed Charges,47% of Total Billed Charges,30.55,90,
DISP RESUCITATION BG,2010209,CDM,270,RC,,,Outpatient,,,85.91,85.91,,50.47,58.75,,140.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.47,58.75,,140.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.59,48.41,,115.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,77.32,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,77.32,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,40.38,47,,112.048,Percent of Total Billed Charges,47% of Total Billed Charges,77.32,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,50.47,58.75,,140.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.38,47,,112.048,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.38,47,,112.048,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.38,47,,44.744,Percent of Total Billed Charges,47% of Total Billed Charges,40.38,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,40.38,77.32,
PEAK FLOW SET UP,2010210,CDM,460,RC,94150,HCPCS,Outpatient,,,27.50,27.50,,16.16,58.75,,140.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.16,58.75,,140.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.31,48.41,,115.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,132.82,100,,5.76,fee Schedule,100% of BCBS fee schedule,132.82,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,12.93,47,,112.048,Percent of Total Billed Charges,47% of Total Billed Charges,132.82,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,16.16,58.75,,140.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.93,47,,112.048,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.93,47,,112.048,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,24.41,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,24.41,115,,4.512,Fee Schedule,115% of CMS OPPS Rate,12.93,132.82,
PEAK FLOW POST,2010211,CDM,460,RC,94150,HCPCS,Outpatient,,,6.60,6.60,,3.88,58.75,,126.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.88,58.75,,126.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.2,48.41,,104.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,132.82,100,,4.32,fee Schedule,100% of BCBS fee schedule,132.82,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,3.1,47,,101.352,Percent of Total Billed Charges,47% of Total Billed Charges,132.82,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,3.88,58.75,,126.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.1,47,,101.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.1,47,,101.352,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,7.59,115,,4.512,Fee Schedule,115% of CMS OPPS Rate,7.59,115,,3.008,Fee Schedule,115% of CMS OPPS Rate,3.1,132.82,
PEAK FLOW PRE,2010212,CDM,460,RC,94150,HCPCS,Outpatient,,,6.60,6.60,,3.88,58.75,,115.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.88,58.75,,115.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.2,48.41,,94.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,132.82,100,,3.6,fee Schedule,100% of BCBS fee schedule,132.82,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,3.1,47,,92.12,Percent of Total Billed Charges,47% of Total Billed Charges,132.82,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,3.88,58.75,,115.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.1,47,,92.12,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.1,47,,92.12,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,7.59,115,,3.008,Fee Schedule,115% of CMS OPPS Rate,7.59,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,3.1,132.82,
AIR COMPRESSOR SETUP,2010213,CDM,410,RC,94660,HCPCS,Outpatient,,,55.00,55.00,,32.31,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.31,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,26.63,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,176.61,100,,3.6,fee Schedule,100% of BCBS fee schedule,176.61,100,,21.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,25.85,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,176.61,100,,21.6,Fee Schedule,100% of BCBS PPO fee schedule,32.31,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,25.85,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,25.85,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,38.19,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,38.19,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,25.85,176.61,
AIR COMPRESSOR PER/D,2010214,CDM,410,RC,94660,HCPCS,Outpatient,,,67.00,67.00,,39.36,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.36,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.43,48.41,,50.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,176.61,100,,4.32,fee Schedule,100% of BCBS fee schedule,176.61,100,,38.16,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,31.49,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,176.61,100,,38.16,Fee Schedule,100% of BCBS PPO fee schedule,39.36,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.49,47,,48.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.49,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,38.19,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,38.19,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,31.49,176.61,
PULSE OX PER HOUR,2010215,CDM,460,RC,94760,HCPCS,Outpatient,,,11.00,11.00,,6.46,58.75,,105.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,105.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,86.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.13,100,,3.6,fee Schedule,100% of BCBS fee schedule,2.13,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,5.17,47,,84.224,Percent of Total Billed Charges,47% of Total Billed Charges,2.13,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,6.46,58.75,,105.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,84.224,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,84.224,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,3.38,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,3.38,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,2.13,90,
OXYGEN TENT CANOPY,2010216,CDM,270,RC,94640,HCPCS,Outpatient,,,22.00,22.00,,12.93,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,176.61,100,,3.6,fee Schedule,100% of BCBS fee schedule,176.61,100,,5.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,10.34,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,176.61,100,,5.76,Fee Schedule,100% of BCBS PPO fee schedule,12.93,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.54,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,7.54,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,7.54,176.61,
OXYGEN STANDBY/DAY,2010217,CDM,270,RC,,,Outpatient,,,15.75,15.75,,9.25,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.25,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.62,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.18,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,14.18,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,7.4,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,14.18,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,9.25,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.4,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.4,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.4,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,7.4,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,7.4,14.18,
MDI PER TREATMENT,2010218,CDM,410,RC,94640,HCPCS,Outpatient,,,298.00,298.00,,175.08,58.75,,6.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,175.08,58.75,,6.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,144.26,48.41,,5.536,Percent of Total Billed Charges,48.41% of Total Billed Charges,176.61,100,,43.56,fee Schedule,100% of BCBS fee schedule,176.61,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,140.06,47,,5.376,Percent of Total Billed Charges,47% of Total Billed Charges,176.61,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,175.08,58.75,,6.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,140.06,47,,5.376,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,140.06,47,,5.376,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,7.54,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,7.54,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,7.54,176.61,
MDI SET UP,2010219,CDM,410,RC,94640,HCPCS,Outpatient,,,298.00,298.00,,175.08,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,175.08,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,144.26,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,176.61,100,,87.84,fee Schedule,100% of BCBS fee schedule,176.61,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,140.06,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,176.61,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,175.08,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,140.06,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,140.06,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,7.54,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,7.54,115,,11.28,Fee Schedule,115% of CMS OPPS Rate,7.54,176.61,
CPAP/BIPAP SET UP,2010223,CDM,410,RC,94660,HCPCS,Outpatient,,,269.55,269.55,,158.36,58.75,,31.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,158.36,58.75,,31.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,130.49,48.41,,26.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,176.61,100,,3.6,fee Schedule,100% of BCBS fee schedule,176.61,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,126.69,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,176.61,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,158.36,58.75,,31.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,126.69,47,,25.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,126.69,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,38.19,115,,11.28,Fee Schedule,115% of CMS OPPS Rate,38.19,115,,19.928,Fee Schedule,115% of CMS OPPS Rate,38.19,176.61,
CPAP/BIPAP PER DAY,2010224,CDM,410,RC,94660,HCPCS,Outpatient,,,245.00,245.00,,143.94,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,143.94,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,118.6,48.41,,37.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,176.61,100,,3.6,fee Schedule,100% of BCBS fee schedule,176.61,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,115.15,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,176.61,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,143.94,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,115.15,47,,36.848,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,115.15,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,38.19,115,,19.928,Fee Schedule,115% of CMS OPPS Rate,38.19,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,38.19,176.61,
BACTERIA FILTERNEB,2010225,CDM,270,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,6.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,6.016,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
PULSE OX CHECK,2010228,CDM,460,RC,94760,HCPCS,Outpatient,,,130.00,130.00,,76.38,58.75,,14.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.38,58.75,,14.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.93,48.41,,12.008,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.13,100,,3.6,fee Schedule,100% of BCBS fee schedule,2.13,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,61.1,47,,11.656,Percent of Total Billed Charges,47% of Total Billed Charges,2.13,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,76.38,58.75,,14.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,61.1,47,,11.656,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,61.1,47,,11.656,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,3.38,115,,3.008,Fee Schedule,115% of CMS OPPS Rate,3.38,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,2.13,90,
MDI AEROCHAMBER,2010229,CDM,270,RC,94150,HCPCS,Outpatient,,,224.00,224.00,,131.6,58.75,,88.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,131.6,58.75,,88.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,108.44,48.41,,72.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,132.82,100,,3.6,fee Schedule,100% of BCBS fee schedule,132.82,100,,43.56,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,105.28,47,,70.688,Percent of Total Billed Charges,47% of Total Billed Charges,132.82,100,,43.56,Fee Schedule,100% of BCBS PPO fee schedule,131.6,58.75,,88.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,105.28,47,,70.688,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,105.28,47,,70.688,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.41,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,24.41,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,24.41,132.82,
PEAK FLOW STUDY,2010232,CDM,460,RC,94150,HCPCS,Outpatient,,,32.00,32.00,,18.8,58.75,,148.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,148.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,121.992,Percent of Total Billed Charges,48.41% of Total Billed Charges,132.82,100,,13.68,fee Schedule,100% of BCBS fee schedule,132.82,100,,87.84,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,15.04,47,,118.44,Percent of Total Billed Charges,47% of Total Billed Charges,132.82,100,,87.84,Fee Schedule,100% of BCBS PPO fee schedule,18.8,58.75,,148.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,118.44,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,118.44,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,24.41,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,24.41,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,15.04,132.82,
T-TUBE,2010233,CDM,270,RC,94640,HCPCS,Outpatient,,,2.00,2.00,,1.18,58.75,,10.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,10.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,8.736,Percent of Total Billed Charges,48.41% of Total Billed Charges,176.61,100,,5.76,fee Schedule,100% of BCBS fee schedule,176.61,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,0.94,47,,8.48,Percent of Total Billed Charges,47% of Total Billed Charges,176.61,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,1.18,58.75,,10.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,8.48,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,8.48,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.3,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,2.3,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,0.94,176.61,
BACTERIA FILTER-PFT,2010235,CDM,270,RC,,,Outpatient,,,14.30,14.30,,8.4,58.75,,31.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.4,58.75,,31.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.92,48.41,,25.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.87,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,12.87,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,6.72,47,,25.024,Percent of Total Billed Charges,47% of Total Billed Charges,12.87,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,8.4,58.75,,31.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.72,47,,25.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.72,47,,25.024,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.72,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,6.72,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.72,12.87,
AEROSOL DRAINAGE BAG,2010239,CDM,270,RC,94150,HCPCS,Outpatient,,,6.00,6.00,,3.53,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,50.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,132.82,100,,6.48,fee Schedule,100% of BCBS fee schedule,132.82,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,2.82,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,132.82,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,3.53,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,48.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.9,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,6.9,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,2.82,132.82,
ETCO2 DETECTORS,2010240,CDM,270,RC,,,Outpatient,,,68.00,68.00,,39.95,58.75,,78.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.95,58.75,,78.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.92,48.41,,64.736,Percent of Total Billed Charges,48.41% of Total Billed Charges,61.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,61.2,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,31.96,47,,62.848,Percent of Total Billed Charges,47% of Total Billed Charges,61.2,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,39.95,58.75,,78.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.96,47,,62.848,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.96,47,,62.848,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.96,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,31.96,47,,22.752,Percent of Total Billed Charges,47% of Total Billed Charges,31.96,61.2,
RESP ASSESS/EVAL,2010241,CDM,460,RC,94664,HCPCS,Outpatient,,,98.00,98.00,,57.58,58.75,,8.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.58,58.75,,8.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.44,48.41,,7.24,Percent of Total Billed Charges,48.41% of Total Billed Charges,176.61,100,,3.6,fee Schedule,100% of BCBS fee schedule,176.61,100,,13.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,46.06,47,,7.032,Percent of Total Billed Charges,47% of Total Billed Charges,176.61,100,,13.68,Fee Schedule,100% of BCBS PPO fee schedule,57.58,58.75,,8.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.06,47,,7.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,46.06,47,,7.032,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,17.02,115,,22.752,Fee Schedule,115% of CMS OPPS Rate,17.02,115,,45.872,Fee Schedule,115% of CMS OPPS Rate,17.02,176.61,
DISP P-OX PROBEADUL,2010242,CDM,270,RC,,,Outpatient,,,16.00,16.00,,9.4,58.75,,3.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.4,58.75,,3.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.75,48.41,,2.672,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.4,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,14.4,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,7.52,47,,2.592,Percent of Total Billed Charges,47% of Total Billed Charges,14.4,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,58.75,,3.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.52,47,,2.592,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.52,47,,2.592,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.52,47,,45.872,Percent of Total Billed Charges,47% of Total Billed Charges,7.52,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,7.52,14.4,
DISP P-OX PROBES NEO,2010243,CDM,270,RC,,,Outpatient,,,31.00,31.00,,18.21,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.21,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.01,48.41,,1.16,Percent of Total Billed Charges,48.41% of Total Billed Charges,27.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,27.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,14.57,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,27.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,18.21,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.57,47,,1.128,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.57,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.57,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,14.57,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,14.57,27.9,
ARTERIAL PUNCTURE,2010245,CDM,410,RC,36600,HCPCS,Outpatient,,,188.00,188.00,,110.45,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,110.45,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,91.01,48.41,,8.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,119.84,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,119.84,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,88.36,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,119.84,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,110.45,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,88.36,47,,7.896,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,88.36,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,15.48,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,15.48,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,15.48,119.84,
SUCTIONING OF AIRWAY,2010246,CDM,410,RC,31720,HCPCS,Outpatient,,,315.00,315.00,,185.06,58.75,,9.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,185.06,58.75,,9.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,152.49,48.41,,8,Percent of Total Billed Charges,48.41% of Total Billed Charges,201.6,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,201.6,100,,6.48,Fee Schedule,100% of ASC Tier Groupings,148.05,47,,7.768,Percent of Total Billed Charges,47% of Total Billed Charges,201.6,100,,6.48,Fee Schedule,100% of ASC Tier Groupings,185.06,58.75,,9.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,148.05,47,,7.768,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,148.05,47,,7.768,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,54.86,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,54.86,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,54.86,201.6,
BIPAP CIRCUIT,2010247,CDM,270,RC,,,Outpatient,,,22.55,22.55,,13.25,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.25,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.92,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,20.3,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,10.6,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,20.3,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,13.25,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.6,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.6,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.6,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,10.6,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,10.6,20.3,
BIPAP FULL FACEMASK,2010248,CDM,270,RC,,,Outpatient,,,66.55,66.55,,39.1,58.75,,2.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.1,58.75,,2.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.22,48.41,,1.992,Percent of Total Billed Charges,48.41% of Total Billed Charges,59.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,59.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,31.28,47,,1.936,Percent of Total Billed Charges,47% of Total Billed Charges,59.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,39.1,58.75,,2.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.28,47,,1.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.28,47,,1.936,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.28,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,31.28,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,31.28,59.9,
BIPAP/CPAP NOSEMASK,2010249,CDM,270,RC,,,Outpatient,,,34.00,34.00,,19.98,58.75,,5.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.98,58.75,,5.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.46,48.41,,4.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.6,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,30.6,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,15.98,47,,4.064,Percent of Total Billed Charges,47% of Total Billed Charges,30.6,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,19.98,58.75,,5.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.98,47,,4.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.98,47,,4.064,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.98,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,15.98,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,15.98,30.6,
SMOKING/TOBACCO COUNS. 3-10 MI,2010257,CDM,410,RC,99406,HCPCS,Outpatient,,,130.00,130.00,,76.38,58.75,,7.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.38,58.75,,7.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.93,48.41,,6.16,Percent of Total Billed Charges,48.41% of Total Billed Charges,26.23,100,,3.6,fee Schedule,100% of BCBS fee schedule,26.23,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,61.1,47,,5.976,Percent of Total Billed Charges,47% of Total Billed Charges,26.23,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,76.38,58.75,,7.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,61.1,47,,5.976,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,61.1,47,,5.976,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,12.19,115,,3.008,Fee Schedule,115% of CMS OPPS Rate,12.19,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,12.19,90,
PULMONARY STRESS TESTING,2010258,CDM,460,RC,94618,HCPCS,Outpatient,,,167.15,167.15,,98.2,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,98.2,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,80.92,48.41,,50.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,104.67,100,,3.6,fee Schedule,100% of BCBS fee schedule,104.67,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,78.56,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,104.67,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,98.2,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,78.56,47,,48.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,78.56,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,35.06,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,35.06,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,35.06,104.67,
LARYNGEAL MASK AIRWAY,2010259,CDM,270,RC,,,Outpatient,,,18.70,18.70,,10.99,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.99,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.05,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.83,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,16.83,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,8.79,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,16.83,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,10.99,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.79,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.79,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.79,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.79,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,8.79,16.83,
TRACHEOSTOMY COLLAR,2010260,CDM,270,RC,,,Outpatient,,,6.90,6.90,,4.05,58.75,,25.848,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.05,58.75,,25.848,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.34,48.41,,21.304,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.21,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.21,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,3.24,47,,20.68,Percent of Total Billed Charges,47% of Total Billed Charges,6.21,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.05,58.75,,25.848,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.24,47,,20.68,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.24,47,,20.68,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.24,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,3.24,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.24,6.21,
OXYGEN TUBING CONNECTOR,2010261,CDM,270,RC,,,Outpatient,,,3.00,3.00,,1.76,58.75,,8.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.76,58.75,,8.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.45,48.41,,6.76,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.7,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.7,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,1.41,47,,6.56,Percent of Total Billed Charges,47% of Total Billed Charges,2.7,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,1.76,58.75,,8.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,6.56,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.41,47,,6.56,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,2.7,
DISP. CO2 INDICATOR,2010262,CDM,270,RC,,,Outpatient,,,21.00,21.00,,12.34,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.34,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.17,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,18.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,18.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,12.34,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.87,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.87,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.87,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,18.9,
HIGH FLOW NASAL CANNULA,2010263,CDM,270,RC,,,Outpatient,,,20.65,20.65,,12.13,58.75,,63.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.13,58.75,,63.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,10,48.41,,52.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.59,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,18.59,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,9.71,47,,50.536,Percent of Total Billed Charges,47% of Total Billed Charges,18.59,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,12.13,58.75,,63.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.71,47,,50.536,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.71,47,,50.536,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.71,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,9.71,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,9.71,18.59,
ORAL AIRWAY,2010264,CDM,270,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,55.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,55.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,45.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,44.56,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,55.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,44.56,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,44.56,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
DISP INTUBATION STYLET,2010265,CDM,270,RC,,,Outpatient,,,5.15,5.15,,3.03,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.03,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.49,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.64,90,,53.28,Percent of Total Billed Charges,90% of Total Billed Charges,4.64,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.42,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,4.64,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,3.03,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.42,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.42,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.42,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.42,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.42,4.64,
THOMAS TUBE HOLDER,2010266,CDM,270,RC,,,Outpatient,,,10.80,10.80,,6.35,58.75,,171.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.35,58.75,,171.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.23,48.41,,141.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.72,90,,105.84,Percent of Total Billed Charges,90% of Total Billed Charges,9.72,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,5.08,47,,137.24,Percent of Total Billed Charges,47% of Total Billed Charges,9.72,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.35,58.75,,171.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.08,47,,137.24,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.08,47,,137.24,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.08,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.08,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.08,9.72,
FIB OPTIC MET DISP LARYN BLADE,2010267,CDM,270,RC,,,Outpatient,,,15.90,15.90,,9.34,58.75,,79.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.34,58.75,,79.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.7,48.41,,65.448,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.31,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,14.31,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,7.47,47,,63.544,Percent of Total Billed Charges,47% of Total Billed Charges,14.31,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,9.34,58.75,,79.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.47,47,,63.544,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.47,47,,63.544,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.47,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,7.47,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,7.47,14.31,
C-MAC DISP LARYN BLADE,2010268,CDM,410,RC,,,Outpatient,,,130.00,130.00,,76.38,58.75,,24.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.38,58.75,,24.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.93,48.41,,20.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,117,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,117,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,61.1,47,,19.744,Percent of Total Billed Charges,47% of Total Billed Charges,117,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,76.38,58.75,,24.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,61.1,47,,19.744,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,61.1,47,,19.744,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,61.1,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,61.1,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,61.1,117,
NEBULIZER DISP SETUP BAGS,2010269,CDM,270,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,39.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,39.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,32.376,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,114.48,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,31.432,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,39.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,31.432,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,31.432,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
OSC EXPIRATORY PRESS THER SYS,2010270,CDM,270,RC,94728,HCPCS,Outpatient,,,55.00,55.00,,32.31,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.31,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,26.63,48.41,,3.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,242.98,100,,13.68,fee Schedule,100% of BCBS fee schedule,242.98,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,25.85,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,242.98,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,32.31,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,25.85,47,,3.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,25.85,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,43.64,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,43.64,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,25.85,242.98,
ETCO2 AIRWAY ADAPTER,2010271,CDM,270,RC,,,Outpatient,,,17.45,17.45,,10.25,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.25,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.45,48.41,,14.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.71,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,15.71,90,,53.28,Percent of Total Billed Charges,90% of Total Billed Charges,8.2,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,15.71,90,,53.28,Percent of Total Billed Charges,90% of Total Billed Charges,10.25,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.2,47,,14.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.2,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.2,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.2,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.2,15.71,
BACTERIA FILTER,2010272,CDM,270,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,39.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,39.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,32.92,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,105.84,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,31.96,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,105.84,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,39.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,31.96,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,31.96,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
HIGH FLOW DISP PATIENT CIRCUIT,2010273,CDM,270,RC,,,Outpatient,,,134.40,134.40,,78.96,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,78.96,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,65.06,48.41,,50.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,120.96,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,120.96,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,63.17,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,120.96,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,78.96,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,63.17,47,,48.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,63.17,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,63.17,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,63.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,63.17,120.96,
VAPOTHERM,2010274,CDM,410,RC,,,Outpatient,,,118.52,118.52,,69.63,58.75,,21.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.63,58.75,,21.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.38,48.41,,17.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,106.67,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,106.67,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,55.7,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,106.67,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,69.63,58.75,,21.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.7,47,,17.296,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,55.7,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,55.7,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,55.7,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,55.7,106.67,
FLEXIBLE TRACH ADAPTER,2010275,CDM,270,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,15.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,15.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,13.168,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,114.48,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,12.784,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,114.48,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,15.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,12.784,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,12.784,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
EKG 3CH W COM INTERP,2020017,CDM,730,RC,,,Outpatient,,,365.00,365.00,,214.44,58.75,,79.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,214.44,58.75,,79.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,176.7,48.41,,65.448,Percent of Total Billed Charges,48.41% of Total Billed Charges,328.5,90,,182.16,Percent of Total Billed Charges,90% of Total Billed Charges,328.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,171.55,47,,63.544,Percent of Total Billed Charges,47% of Total Billed Charges,328.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,214.44,58.75,,79.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,171.55,47,,63.544,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,171.55,47,,63.544,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,171.55,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,171.55,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,90,328.5,
CARDIAC MONITOR,2020020,CDM,730,RC,93041,HCPCS,Outpatient,,,169.00,169.00,,99.29,58.75,,48.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,99.29,58.75,,48.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,81.81,48.41,,39.888,Percent of Total Billed Charges,48.41% of Total Billed Charges,52.81,100,,12.24,fee Schedule,100% of BCBS fee schedule,52.81,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,79.43,47,,38.728,Percent of Total Billed Charges,47% of Total Billed Charges,52.81,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,99.29,58.75,,48.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,79.43,47,,38.728,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,79.43,47,,38.728,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,6.27,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,6.27,115,,27.824,Fee Schedule,115% of CMS OPPS Rate,6.27,99.29,
HOLTER MON Q0022 24H,2020061,CDM,985,RC,,,Outpatient,,,30.50,30.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
EKG OVERREADS,2020063,CDM,730,RC,,,Outpatient,,,52.50,52.50,,30.84,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.84,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.42,48.41,,30.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,47.25,90,,64.656,Percent of Total Billed Charges,90% of Total Billed Charges,47.25,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,24.68,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,47.25,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,30.84,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.68,47,,29.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,24.68,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,24.68,47,,55.272,Percent of Total Billed Charges,47% of Total Billed Charges,24.68,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,24.68,90,
STERILE BANDAGING LG,2100001,CDM,270,RC,,,Outpatient,,,83.60,83.60,,49.12,58.75,,48.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.12,58.75,,48.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.47,48.41,,40.28,Percent of Total Billed Charges,48.41% of Total Billed Charges,75.24,90,,219.6,Percent of Total Billed Charges,90% of Total Billed Charges,75.24,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,39.29,47,,39.104,Percent of Total Billed Charges,47% of Total Billed Charges,75.24,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,49.12,58.75,,48.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,39.29,47,,39.104,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,39.29,47,,39.104,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,39.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,39.29,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,39.29,75.24,
THERABAND,2100008,CDM,270,RC,99070,HCPCS,Outpatient,,,10.00,10.00,,5.88,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.88,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.84,48.41,,50.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,9,90,,182.16,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,9,90,,182.16,Percent of Total Billed Charges,90% of Total Billed Charges,5.88,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,48.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.7,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,9,
ICE MASSAGE,2100009,CDM,420,RC,97010,HCPCS,Outpatient,,,38.00,38.00,,22.33,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.33,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.4,48.41,,22.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.18,100,,7.2,fee Schedule,100% of BCBS fee schedule,6.18,100,,12.24,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,17.86,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,6.18,100,,12.24,Fee Schedule,100% of BCBS PPO fee schedule,22.33,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,21.432,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.86,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,6.58,115,,7.144,Fee Schedule,115% of CMS OPPS Rate,6.58,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,6.18,150,
BURN DEBRIDEMENT,2100015,CDM,420,RC,16020,HCPCS,Outpatient,,,85.00,85.00,GP,49.94,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.94,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.15,48.41,,30.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,6.48,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,90,Fee Schedule,100% of ASC Tier Groupings,39.95,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,90,Fee Schedule,100% of ASC Tier Groupings,49.94,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,39.95,47,,29.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,39.95,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,56.1,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,56.1,115,,4.136,Fee Schedule,115% of CMS OPPS Rate,39.95,191.52,
E-STIM ATTENDED,2100017,CDM,420,RC,97032,HCPCS,Outpatient,,,130.00,130.00,GP,76.38,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.38,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.93,48.41,,14.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.09,100,,397.44,fee Schedule,100% of BCBS fee schedule,15.09,100,,64.656,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,61.1,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,15.09,100,,64.656,Fee Schedule,100% of BCBS PPO fee schedule,76.38,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,61.1,47,,14.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,61.1,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,15.25,115,,4.136,Fee Schedule,115% of CMS OPPS Rate,15.25,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,15.09,150,
ETHYL CHLORIDE SPRAY,2100019,CDM,420,RC,97110,HCPCS,Outpatient,,,46.00,46.00,,27.03,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.03,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.27,48.41,,19.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,9.36,fee Schedule,100% of BCBS fee schedule,30.96,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,21.62,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,27.03,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.62,47,,19.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,21.62,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,30.68,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,21.62,150,
IONTOPHORESIS,2100020,CDM,420,RC,97033,HCPCS,Outpatient,,,34.00,34.00,,19.98,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.98,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.46,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.84,100,,5.76,fee Schedule,100% of BCBS fee schedule,20.84,100,,219.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,15.98,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,20.84,100,,219.6,Fee Schedule,100% of BCBS PPO fee schedule,19.98,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.98,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.98,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,19.78,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,19.78,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,15.98,150,
PT EVAL LOW COMPLEX 20 MIN,2100022,CDM,420,RC,97161,HCPCS,Outpatient,,,169.00,169.00,,99.29,58.75,,67.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,99.29,58.75,,67.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,81.81,48.41,,55.768,Percent of Total Billed Charges,48.41% of Total Billed Charges,86.3,100,,3.6,fee Schedule,100% of BCBS fee schedule,86.3,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,79.43,47,,54.144,Percent of Total Billed Charges,47% of Total Billed Charges,86.3,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,99.29,58.75,,67.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,79.43,47,,54.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,79.43,47,,54.144,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,104.43,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,104.43,115,,95.128,Fee Schedule,115% of CMS OPPS Rate,79.43,150,
GAIT TRAINING,2100023,CDM,420,RC,97116,HCPCS,Outpatient,,,103.00,103.00,GP,60.51,58.75,,29,Percent of Total Billed Charges,58.75% of Total Billed Charges,60.51,58.75,,29,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.86,48.41,,23.896,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.63,100,,3.6,fee Schedule,100% of BCBS fee schedule,30.63,100,,7.2,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,48.41,47,,23.2,Percent of Total Billed Charges,47% of Total Billed Charges,30.63,100,,7.2,Fee Schedule,100% of BCBS PPO fee schedule,60.51,58.75,,29,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.41,47,,23.2,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,48.41,47,,23.2,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,30.68,115,,95.128,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,6.392,Fee Schedule,115% of CMS OPPS Rate,30.63,150,
HOT PACK/COLD PACK,2100026,CDM,420,RC,97010,HCPCS,Outpatient,,,130.00,130.00,GP,76.38,58.75,,35.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.38,58.75,,35.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.93,48.41,,29.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.18,100,,41.04,fee Schedule,100% of BCBS fee schedule,6.18,100,,6.48,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,61.1,47,,28.536,Percent of Total Billed Charges,47% of Total Billed Charges,6.18,100,,6.48,Fee Schedule,100% of BCBS PPO fee schedule,76.38,58.75,,35.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,61.1,47,,28.536,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,61.1,47,,28.536,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,6.58,115,,6.392,Fee Schedule,115% of CMS OPPS Rate,6.58,115,,47,Fee Schedule,115% of CMS OPPS Rate,6.18,150,
CONTRAST BATH,2100029,CDM,420,RC,97034,HCPCS,Outpatient,,,79.00,79.00,,46.41,58.75,,6.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.41,58.75,,6.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.24,48.41,,5.536,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.25,100,,100.08,fee Schedule,100% of BCBS fee schedule,15.25,100,,397.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,37.13,47,,5.376,Percent of Total Billed Charges,47% of Total Billed Charges,15.25,100,,397.44,Fee Schedule,100% of BCBS PPO fee schedule,46.41,58.75,,6.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.13,47,,5.376,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,37.13,47,,5.376,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,14.4,115,,47,Fee Schedule,115% of CMS OPPS Rate,14.4,115,,33.768,Fee Schedule,115% of CMS OPPS Rate,14.4,150,
HOME CERVICAL TX,2100031,CDM,420,RC,97012,HCPCS,Outpatient,,,116.60,116.60,GP,68.5,58.75,,29.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,68.5,58.75,,29.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,56.45,48.41,,24.008,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.43,100,,3.6,fee Schedule,100% of BCBS fee schedule,15.43,100,,9.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,54.8,47,,23.312,Percent of Total Billed Charges,47% of Total Billed Charges,15.43,100,,9.36,Fee Schedule,100% of BCBS PPO fee schedule,68.5,58.75,,29.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,54.8,47,,23.312,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,54.8,47,,23.312,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,15.25,115,,33.768,Fee Schedule,115% of CMS OPPS Rate,15.25,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,15.25,150,
BED MOBILITY/TRANFER,2100032,CDM,420,RC,97530,HCPCS,Outpatient,,,104.00,104.00,GP,61.1,58.75,,30.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.1,58.75,,30.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.35,48.41,,24.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,39.3,100,,3.6,fee Schedule,100% of BCBS fee schedule,39.3,100,,5.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,48.88,47,,24.16,Percent of Total Billed Charges,47% of Total Billed Charges,39.3,100,,5.76,Fee Schedule,100% of BCBS PPO fee schedule,61.1,58.75,,30.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.88,47,,24.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,48.88,47,,24.16,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,36.39,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,36.39,115,,114.68,Fee Schedule,115% of CMS OPPS Rate,36.39,150,
MASSAGE,2100036,CDM,420,RC,97124,HCPCS,Outpatient,,,130.00,130.00,GP,76.38,58.75,,24.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.38,58.75,,24.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.93,48.41,,20.528,Percent of Total Billed Charges,48.41% of Total Billed Charges,29.3,100,,3.6,fee Schedule,100% of BCBS fee schedule,29.3,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,61.1,47,,19.928,Percent of Total Billed Charges,47% of Total Billed Charges,29.3,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,76.38,58.75,,24.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,61.1,47,,19.928,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,61.1,47,,19.928,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,31.12,115,,114.68,Fee Schedule,115% of CMS OPPS Rate,31.12,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,29.3,150,
PARAFFIN,2100042,CDM,420,RC,97018,HCPCS,Outpatient,,,57.00,57.00,GP,33.49,58.75,,43.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.49,58.75,,43.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.59,48.41,,36.016,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.84,100,,3.6,fee Schedule,100% of BCBS fee schedule,5.84,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,26.79,47,,34.968,Percent of Total Billed Charges,47% of Total Billed Charges,5.84,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,33.49,58.75,,43.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,34.968,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.79,47,,34.968,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,6.26,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,6.26,115,,3.76,Fee Schedule,115% of CMS OPPS Rate,5.84,150,
MEASUREMNT/FITNG-EXT,2100043,CDM,420,RC,99070,HCPCS,Outpatient,,,79.00,79.00,,46.41,58.75,,74.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.41,58.75,,74.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.24,48.41,,61.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,71.1,90,,82.08,Percent of Total Billed Charges,90% of Total Billed Charges,71.1,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,37.13,47,,59.56,Percent of Total Billed Charges,47% of Total Billed Charges,71.1,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,46.41,58.75,,74.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.13,47,,59.56,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,37.13,47,,59.56,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,37.13,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,37.13,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,37.13,150,
STER BANDAGE SM,2100051,CDM,270,RC,,,Outpatient,,,38.00,38.00,,22.33,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.33,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.4,48.41,,31.76,Percent of Total Billed Charges,48.41% of Total Billed Charges,34.2,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,34.2,90,,100.08,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,34.2,90,,100.08,Percent of Total Billed Charges,90% of Total Billed Charges,22.33,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,30.832,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.86,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,47,,207.552,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,34.2,
TENS APPLIC,2100052,CDM,420,RC,64550,HCPCS,Outpatient,,,51.00,51.00,,29.96,58.75,,39.48,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.96,58.75,,39.48,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.69,48.41,,32.528,Percent of Total Billed Charges,48.41% of Total Billed Charges,45.9,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,45.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,23.97,47,,31.584,Percent of Total Billed Charges,47% of Total Billed Charges,45.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,29.96,58.75,,39.48,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,31.584,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.97,47,,31.584,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,23.97,47,,207.552,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,150,
TENS RENTAL/DAYS,2100054,CDM,420,RC,64550,HCPCS,Outpatient,,,11.00,11.00,,6.46,58.75,,45.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,45.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,37.176,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,45.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,36.096,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,5.17,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,150,
THER-EX 1-15,2100055,CDM,420,RC,97110,HCPCS,Outpatient,,,144.00,144.00,GP,84.6,58.75,,58.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.6,58.75,,58.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.71,48.41,,48.6,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,4.32,fee Schedule,100% of BCBS fee schedule,30.96,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,67.68,47,,47.192,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,84.6,58.75,,58.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,67.68,47,,47.192,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,67.68,47,,47.192,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,30.68,115,,3.008,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.68,150,
MANUAL THERAPY,2100056,CDM,420,RC,97140,HCPCS,Outpatient,,,61.70,61.70,GP,36.25,58.75,,85.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.25,58.75,,85.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.87,48.41,,70.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.52,100,,3.6,fee Schedule,100% of BCBS fee schedule,28.52,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,29,47,,68.656,Percent of Total Billed Charges,47% of Total Billed Charges,28.52,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,36.25,58.75,,85.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29,47,,68.656,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,29,47,,68.656,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,28.98,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,28.98,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,28.52,150,
US /EMS COMBO,2100057,CDM,420,RC,97035,HCPCS,Outpatient,,,75.90,75.90,,44.59,58.75,,69.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.59,58.75,,69.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.74,48.41,,56.912,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.57,100,,3.6,fee Schedule,100% of BCBS fee schedule,14.57,100,,82.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,35.67,47,,55.256,Percent of Total Billed Charges,47% of Total Billed Charges,14.57,100,,82.08,Fee Schedule,100% of BCBS PPO fee schedule,44.59,58.75,,69.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.67,47,,55.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,35.67,47,,55.256,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,14.72,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,14.72,115,,21.432,Fee Schedule,115% of CMS OPPS Rate,14.57,150,
TRAPEEZE RENTAL/DAY,2100063,CDM,420,RC,97799,HCPCS,Outpatient,,,14.30,14.30,,8.4,58.75,,66.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.4,58.75,,66.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.92,48.41,,54.512,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.87,90,,3.6,fee Schedule,90% of BCBS fee schedule,12.87,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.72,47,,52.92,Percent of Total Billed Charges,47% of Total Billed Charges,12.87,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,8.4,58.75,,66.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.72,47,,52.92,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.72,47,,52.92,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,6.72,47,,52.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.72,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.72,150,
TRAPEEZE SET UP,2100064,CDM,270,RC,97799,HCPCS,Outpatient,,,62.00,62.00,,36.43,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.43,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.01,48.41,,58.864,Percent of Total Billed Charges,48.41% of Total Billed Charges,55.8,90,,3.96,fee Schedule,90% of BCBS fee schedule,55.8,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,29.14,47,,57.152,Percent of Total Billed Charges,47% of Total Billed Charges,55.8,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,36.43,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.14,47,,57.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,29.14,47,,57.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.14,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,29.14,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,29.14,55.8,
ULTRASOUND,2100068,CDM,420,RC,97035,HCPCS,Outpatient,,,64.25,64.25,GP,37.75,58.75,,98.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.75,58.75,,98.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.1,48.41,,81.216,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.57,100,,3.6,fee Schedule,100% of BCBS fee schedule,14.57,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,30.2,47,,78.848,Percent of Total Billed Charges,47% of Total Billed Charges,14.57,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,37.75,58.75,,98.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.2,47,,78.848,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,30.2,47,,78.848,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,14.72,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,14.72,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,14.57,150,
WHIRLPOOL,2100071,CDM,420,RC,97022,HCPCS,Outpatient,,,53.00,53.00,,31.14,58.75,,39.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.14,58.75,,39.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.66,48.41,,32.608,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.75,100,,4.32,fee Schedule,100% of BCBS fee schedule,17.75,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,24.91,47,,31.656,Percent of Total Billed Charges,47% of Total Billed Charges,17.75,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,31.14,58.75,,39.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.91,47,,31.656,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,24.91,47,,31.656,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,16.11,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,16.11,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,16.11,150,
ATTENDED WHIRLPOOL,2100072,CDM,420,RC,97022,HCPCS,Outpatient,,,93.00,93.00,,54.64,58.75,,82.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,54.64,58.75,,82.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.02,48.41,,68.064,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.75,100,,15.84,fee Schedule,100% of BCBS fee schedule,17.75,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,43.71,47,,66.08,Percent of Total Billed Charges,47% of Total Billed Charges,17.75,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,54.64,58.75,,82.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,43.71,47,,66.08,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,43.71,47,,66.08,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,16.11,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,16.11,115,,42.864,Fee Schedule,115% of CMS OPPS Rate,16.11,150,
WHIRLPOOL STERLE,2100075,CDM,420,RC,97022,HCPCS,Outpatient,,,158.40,158.40,GP,93.06,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,93.06,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.68,48.41,,58.864,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.75,100,,3.6,fee Schedule,100% of BCBS fee schedule,17.75,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,74.45,47,,57.152,Percent of Total Billed Charges,47% of Total Billed Charges,17.75,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,93.06,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,74.45,47,,57.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,74.45,47,,57.152,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,16.11,115,,42.864,Fee Schedule,115% of CMS OPPS Rate,16.11,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,16.11,150,
PHONOPHORESIS,2100086,CDM,420,RC,97035,HCPCS,Outpatient,,,82.00,82.00,GP,48.18,58.75,,81.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.18,58.75,,81.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.7,48.41,,67.192,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.57,100,,3.6,fee Schedule,100% of BCBS fee schedule,14.57,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,38.54,47,,65.24,Percent of Total Billed Charges,47% of Total Billed Charges,14.57,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,48.18,58.75,,81.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.54,47,,65.24,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,38.54,47,,65.24,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,14.72,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,14.72,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,14.57,150,
RE EVALUATION PT,2100090,CDM,420,RC,97164,HCPCS,Outpatient,,,84.00,84.00,,49.35,58.75,,89.256,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.35,58.75,,89.256,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.66,48.41,,73.544,Percent of Total Billed Charges,48.41% of Total Billed Charges,59.03,100,,3.6,fee Schedule,100% of BCBS fee schedule,59.03,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,39.48,47,,71.4,Percent of Total Billed Charges,47% of Total Billed Charges,59.03,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,49.35,58.75,,89.256,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,39.48,47,,71.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,39.48,47,,71.4,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,71.6,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,71.6,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,39.48,150,
MECHNICAL/TRACTION,2100096,CDM,420,RC,97012,HCPCS,Outpatient,,,96.00,96.00,GP,56.4,58.75,,25.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,56.4,58.75,,25.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.47,48.41,,21.224,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.43,100,,3.6,fee Schedule,100% of BCBS fee schedule,15.43,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,45.12,47,,20.608,Percent of Total Billed Charges,47% of Total Billed Charges,15.43,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,56.4,58.75,,25.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.12,47,,20.608,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,45.12,47,,20.608,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,15.25,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,15.25,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,15.25,150,
TREATMENT SPEECH/LANGUAGE IND,2100098,CDM,440,RC,92507,HCPCS,Outpatient,,,125.50,125.50,,73.73,58.75,,7.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.73,58.75,,7.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,60.75,48.41,,6.352,Percent of Total Billed Charges,48.41% of Total Billed Charges,80.72,100,,3.6,fee Schedule,100% of BCBS fee schedule,80.72,100,,15.84,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,58.99,47,,6.168,Percent of Total Billed Charges,47% of Total Billed Charges,80.72,100,,15.84,Fee Schedule,100% of BCBS PPO fee schedule,73.73,58.75,,7.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,58.99,47,,6.168,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,58.99,47,,6.168,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,80.6,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,80.6,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,58.99,90,
EVAL OF SPEECH FLUENCY,2100099,CDM,444,RC,92521,HCPCS,Outpatient,,,182.60,182.60,GN,107.28,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,107.28,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,88.4,48.41,,19.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,114.57,100,,4.752,fee Schedule,100% of BCBS fee schedule,114.57,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,85.82,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,114.57,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,107.28,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,85.82,47,,19.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,85.82,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,140.27,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,140.27,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,85.82,140.27,
EVAL/SPEECH SOUND PRODUCTION,2100100,CDM,444,RC,92522,HCPCS,Outpatient,,,146.95,146.95,GN,86.33,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.33,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,71.14,48.41,,30.056,Percent of Total Billed Charges,48.41% of Total Billed Charges,93.65,100,,3.6,fee Schedule,100% of BCBS fee schedule,93.65,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,69.07,47,,29.176,Percent of Total Billed Charges,47% of Total Billed Charges,93.65,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,86.33,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,69.07,47,,29.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,69.07,47,,29.176,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,116.71,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,116.71,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,69.07,116.71,
EVAL LANG COMPREHENSION/EXPRSN,2100101,CDM,444,RC,92523,HCPCS,Outpatient,,,316.50,316.50,GN,185.94,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,185.94,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,153.22,48.41,,30.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,196.67,100,,3.6,fee Schedule,100% of BCBS fee schedule,196.67,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,148.76,47,,29.536,Percent of Total Billed Charges,47% of Total Billed Charges,196.67,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,185.94,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,148.76,47,,29.536,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,148.76,47,,29.536,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,239.78,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,239.78,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,90,239.78,
BEHR & QUAL ANALS VOICE & REAS,2100102,CDM,440,RC,92524,HCPCS,Outpatient,,,140.75,140.75,GN,82.69,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,82.69,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,68.14,48.41,,19.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,91.63,100,,13.68,fee Schedule,100% of BCBS fee schedule,91.63,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,66.15,47,,18.48,Percent of Total Billed Charges,47% of Total Billed Charges,91.63,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,82.69,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,66.15,47,,18.48,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,66.15,47,,18.48,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,114.93,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,114.93,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,66.15,114.93,
TREATMNT SWALLOWING DYSFUNCTN,2100103,CDM,440,RC,92526,HCPCS,Outpatient,,,152.00,152.00,GN,89.3,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.3,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.58,48.41,,38.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,88.62,100,,23.04,fee Schedule,100% of BCBS fee schedule,88.62,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,71.44,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,88.62,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,89.3,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,71.44,47,,37.6,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,71.44,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,88.49,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,88.49,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,71.44,90,
EVAL PRSC A&A COM DEVC 1ST HR,2100104,CDM,444,RC,92607,HCPCS,Outpatient,,,209.70,209.70,GN,123.2,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,123.2,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,101.52,48.41,,19.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,130.12,100,,9.36,fee Schedule,100% of BCBS fee schedule,130.12,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,98.56,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,130.12,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,123.2,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,98.56,47,,19.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,98.56,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,128.77,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,128.77,115,,8.272,Fee Schedule,115% of CMS OPPS Rate,90,130.12,
EVAL PRSC SPECH GEN EA ADDL 30,2100105,CDM,440,RC,92608,HCPCS,Outpatient,,,84.20,84.20,GN,49.47,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.47,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.76,48.41,,14.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,75.78,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,75.78,90,,4.752,Percent of Total Billed Charges,90% of Total Billed Charges,39.57,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,75.78,90,,4.752,Percent of Total Billed Charges,90% of Total Billed Charges,49.47,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,39.57,47,,14.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,39.57,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,50.42,115,,8.272,Fee Schedule,115% of CMS OPPS Rate,50.42,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,39.57,90,
THER SERV S G DEVICE PROG/MOD,2100106,CDM,440,RC,92609,HCPCS,Outpatient,,,175.75,175.75,GN,103.25,58.75,,36.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,103.25,58.75,,36.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,85.08,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,109.33,100,,6.48,fee Schedule,100% of BCBS fee schedule,109.33,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,82.6,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,109.33,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,103.25,58.75,,36.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,82.6,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,82.6,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,107.11,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,107.11,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,82.6,109.33,
EVAL ORAL/PHARYNGEAL SWAL FUNC,2100107,CDM,444,RC,92610,HCPCS,Outpatient,,,152.00,152.00,GN,89.3,58.75,,36.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.3,58.75,,36.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.58,48.41,,25.944,Percent of Total Billed Charges,48.41% of Total Billed Charges,136.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,136.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,71.44,47,,25.192,Percent of Total Billed Charges,47% of Total Billed Charges,136.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,89.3,58.75,,36.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,71.44,47,,25.192,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,71.44,47,,25.192,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,74.39,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,74.39,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,71.44,136.8,
ASSESSMENT OF APHASIA,2100108,CDM,440,RC,96105,HCPCS,Outpatient,,,173.50,173.50,GN,101.93,58.75,,23.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,101.93,58.75,,23.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,83.99,48.41,,30.984,Percent of Total Billed Charges,48.41% of Total Billed Charges,156.15,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,156.15,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,81.55,47,,30.08,Percent of Total Billed Charges,47% of Total Billed Charges,156.15,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,101.93,58.75,,23.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,81.55,47,,30.08,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,81.55,47,,30.08,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,101.12,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,101.12,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,81.55,156.15,
STANDARD COGNITIVE PERFMC TEST,2100109,CDM,440,RC,96125,HCPCS,Outpatient,,,189.90,189.90,GN,111.57,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,111.57,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,91.93,48.41,,111.536,Percent of Total Billed Charges,48.41% of Total Billed Charges,110.65,100,,3.96,fee Schedule,100% of BCBS fee schedule,110.65,100,,23.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,89.25,47,,108.288,Percent of Total Billed Charges,47% of Total Billed Charges,110.65,100,,23.04,Fee Schedule,100% of BCBS PPO fee schedule,111.57,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,89.25,47,,108.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,89.25,47,,108.288,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,106.74,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,106.74,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,89.25,111.57,
SENSORY INTGR TECHNQ EA 15 MIN,2100110,CDM,440,RC,97533,HCPCS,Outpatient,,,54.80,54.80,GN,32.2,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.2,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,26.53,48.41,,167.304,Percent of Total Billed Charges,48.41% of Total Billed Charges,51.22,100,,3.6,fee Schedule,100% of BCBS fee schedule,51.22,100,,9.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,25.76,47,,162.432,Percent of Total Billed Charges,47% of Total Billed Charges,51.22,100,,9.36,Fee Schedule,100% of BCBS PPO fee schedule,32.2,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,25.76,47,,162.432,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,25.76,47,,162.432,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,62.19,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,62.19,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,25.76,90,
SELFCARE/HOME MNGMT TRAIN 15MN,2100111,CDM,440,RC,97535,HCPCS,Outpatient,,,55.40,55.40,GN,32.55,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.55,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,26.82,48.41,,223.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,34.32,100,,19.44,fee Schedule,100% of BCBS fee schedule,34.32,100,,5.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,26.04,47,,216.576,Percent of Total Billed Charges,47% of Total Billed Charges,34.32,100,,5.76,Fee Schedule,100% of BCBS PPO fee schedule,32.55,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.04,47,,216.576,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.04,47,,216.576,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,33.88,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,33.88,115,,2.48,Fee Schedule,115% of CMS OPPS Rate,26.04,90,
DEVELOPMENTAL TESTING,2100112,CDM,440,RC,G0451,HCPCS,Outpatient,,,16.40,16.40,GN,9.64,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.64,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.94,48.41,,28.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,75.4,100,,32.4,fee Schedule,100% of BCBS fee schedule,75.4,100,,6.48,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,7.71,47,,27.824,Percent of Total Billed Charges,47% of Total Billed Charges,75.4,100,,6.48,Fee Schedule,100% of BCBS PPO fee schedule,9.64,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.71,47,,27.824,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.71,47,,27.824,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,11.06,115,,2.48,Fee Schedule,115% of CMS OPPS Rate,11.06,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,7.71,90,
DEV COGNIIVE SKILLS EA 15 MIN,2100113,CDM,440,RC,G0515,HCPCS,Outpatient,,,51.00,51.00,GN,29.96,58.75,,31.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.96,58.75,,31.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.69,48.41,,35.632,Percent of Total Billed Charges,48.41% of Total Billed Charges,45.9,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,45.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,23.97,47,,34.592,Percent of Total Billed Charges,47% of Total Billed Charges,45.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,29.96,58.75,,31.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,34.592,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.97,47,,34.592,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,23.97,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,90,
ST G CODE SWALLOW CURRENT STAT,2100114,CDM,440,RC,G8996,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,37.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,37.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,37.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
ST G CODE SWALLOW GOAL STATUS,2100115,CDM,440,RC,G8997,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,135.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,135.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,73.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,135.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
ST G CODE SWALLOW D/C STATUS,2100116,CDM,440,RC,G8998,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,203.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,203.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,115.92,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,203.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
ST G CODE MOTOR SPEECH CURR ST,2100117,CDM,440,RC,G8999,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,270.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,270.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,270.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
ST G CODE MOTOR SPEECH GOAL ST,2100118,CDM,440,RC,G9186,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,34.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,34.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,34.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
ST G CODE MOTOR SPEECH D/C STS,2100119,CDM,440,RC,G9158,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,43.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,43.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,21.384,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,43.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
SPEECH MEDICAID EVAL,2100120,CDM,440,RC,92523,HCPCS,Outpatient,,,77.60,77.60,,45.59,58.75,,51.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.59,58.75,,51.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.57,48.41,,48.8,Percent of Total Billed Charges,48.41% of Total Billed Charges,196.67,100,,4.32,fee Schedule,100% of BCBS fee schedule,196.67,100,,49.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,36.47,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,196.67,100,,49.68,Fee Schedule,100% of BCBS PPO fee schedule,45.59,58.75,,51.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,36.47,47,,47.376,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,36.47,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,239.78,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,239.78,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,36.47,239.78,
SPEECH MEDICAID UNITS >60 MIN,2100121,CDM,440,RC,92507,HCPCS,Outpatient,,,78.55,78.55,,46.15,58.75,,52.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.15,58.75,,52.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.03,48.41,,40.664,Percent of Total Billed Charges,48.41% of Total Billed Charges,80.72,100,,15.048,fee Schedule,100% of BCBS fee schedule,80.72,100,,73.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,36.92,47,,39.48,Percent of Total Billed Charges,47% of Total Billed Charges,80.72,100,,73.44,Fee Schedule,100% of BCBS PPO fee schedule,46.15,58.75,,52.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,36.92,47,,39.48,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,36.92,47,,39.48,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,80.6,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,80.6,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,36.92,90,
SPEECH MEDICAID UNITS <60 MIN,2100122,CDM,440,RC,92507,HCPCS,Outpatient,,,49.15,49.15,,28.88,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.88,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.79,48.41,,48.8,Percent of Total Billed Charges,48.41% of Total Billed Charges,80.72,100,,3.96,fee Schedule,100% of BCBS fee schedule,80.72,100,,115.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,23.1,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,80.72,100,,115.92,Fee Schedule,100% of BCBS PPO fee schedule,28.88,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.1,47,,47.376,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.1,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,80.6,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,80.6,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,23.1,90,
MEDICAID PT EVAL,2200042,CDM,420,RC,97161,HCPCS,Outpatient,,,100.00,100.00,,58.75,58.75,,86.48,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.75,58.75,,86.48,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.41,48.41,,52.672,Percent of Total Billed Charges,48.41% of Total Billed Charges,86.3,100,,13.68,fee Schedule,100% of BCBS fee schedule,86.3,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,47,47,,51.136,Percent of Total Billed Charges,47% of Total Billed Charges,86.3,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,58.75,58.75,,86.48,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47,47,,51.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47,47,,51.136,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,104.43,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,104.43,115,,10.152,Fee Schedule,115% of CMS OPPS Rate,47,150,
MEDICAID UNIT 1-15,2200043,CDM,420,RC,97110,HCPCS,Outpatient,,,51.00,51.00,,29.96,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.96,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.69,48.41,,56.544,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,5.04,fee Schedule,100% of BCBS fee schedule,30.96,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,23.97,47,,54.896,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,29.96,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,54.896,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.97,47,,54.896,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,30.68,115,,10.152,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,16.92,Fee Schedule,115% of CMS OPPS Rate,23.97,150,
MEDICAID UNIT-PTA 1-15,2200044,CDM,420,RC,97110,HCPCS,Outpatient,,,38.00,38.00,UB,22.33,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.33,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.4,48.41,,29.432,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,70.56,fee Schedule,100% of BCBS fee schedule,30.96,100,,21.384,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,17.86,47,,28.576,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,21.384,Fee Schedule,100% of BCBS PPO fee schedule,22.33,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,28.576,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.86,47,,28.576,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,30.68,115,,16.92,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,17.86,150,
BIOFREEZE,2200045,CDM,250,RC,99070,HCPCS,Outpatient,,,11.00,11.00,,6.46,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,71.224,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,69.144,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,69.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,69.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
DRESSING CHANGE SMALL,2200046,CDM,420,RC,97597,HCPCS,Outpatient,,,67.00,67.00,,39.36,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.36,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.43,48.41,,97.208,Percent of Total Billed Charges,48.41% of Total Billed Charges,167.75,100,,3.6,fee Schedule,100% of BCBS fee schedule,167.75,100,,15.048,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,31.49,47,,94.376,Percent of Total Billed Charges,47% of Total Billed Charges,167.75,100,,15.048,Fee Schedule,100% of BCBS PPO fee schedule,39.36,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.49,47,,94.376,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.49,47,,94.376,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,36.96,115,,25.944,Fee Schedule,115% of CMS OPPS Rate,36.96,115,,38.352,Fee Schedule,115% of CMS OPPS Rate,31.49,167.75,
DRESSING CHANGE LARGE,2200047,CDM,420,RC,97598,HCPCS,Outpatient,,,80.00,80.00,,47,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,47,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.73,48.41,,50.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37.6,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.6,47,,48.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,37.6,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,25,115,,38.352,Fee Schedule,115% of CMS OPPS Rate,25,115,,60.536,Fee Schedule,115% of CMS OPPS Rate,25,150,
THER EX 16-30,2200049,CDM,420,RC,97110,HCPCS,Outpatient,,,288.00,288.00,,169.2,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,169.2,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,139.42,48.41,,71.224,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,3.6,fee Schedule,100% of BCBS fee schedule,30.96,100,,13.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,135.36,47,,69.144,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,13.68,Fee Schedule,100% of BCBS PPO fee schedule,169.2,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,135.36,47,,69.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,135.36,47,,69.144,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,30.68,115,,60.536,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.68,169.2,
THER EX 31-45,2200050,CDM,420,RC,97110,HCPCS,Outpatient,,,432.00,432.00,,253.8,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,253.8,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,209.13,48.41,,24.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,11.88,fee Schedule,100% of BCBS fee schedule,30.96,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,203.04,47,,24.16,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,253.8,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,203.04,47,,24.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,203.04,47,,24.16,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,30.68,253.8,
THER EX 46-60,2200051,CDM,420,RC,97110,HCPCS,Outpatient,,,576.00,576.00,,338.4,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,338.4,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,278.84,48.41,,26.416,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,14.4,fee Schedule,100% of BCBS fee schedule,30.96,100,,70.56,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,270.72,47,,25.64,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,70.56,Fee Schedule,100% of BCBS PPO fee schedule,338.4,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,270.72,47,,25.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,270.72,47,,25.64,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,30.68,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,11.168,Fee Schedule,115% of CMS OPPS Rate,30.68,338.4,
MEDICAID UNIT PTA 16-30,2200052,CDM,420,RC,97110,HCPCS,Outpatient,,,74.00,74.00,UB,43.48,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,43.48,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.82,48.41,,19.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,62.64,fee Schedule,100% of BCBS fee schedule,30.96,100,,10.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,34.78,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,10.08,Fee Schedule,100% of BCBS PPO fee schedule,43.48,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,34.78,47,,19.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,34.78,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,30.68,115,,11.168,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,30.68,150,
MEDICAID UNIT PTA 31-45,2200053,CDM,420,RC,97110,HCPCS,Outpatient,,,92.00,92.00,,54.05,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,54.05,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.54,48.41,,22.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,26.136,fee Schedule,100% of BCBS fee schedule,30.96,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,43.24,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,54.05,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,43.24,47,,21.432,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,43.24,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,30.68,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,7.856,Fee Schedule,115% of CMS OPPS Rate,30.68,150,
MEDICAID UTIT-PTA 46-60,2200054,CDM,420,RC,97110,HCPCS,Outpatient,,,110.00,110.00,52,64.63,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.63,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,53.25,48.41,,22.576,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,40.392,fee Schedule,100% of BCBS fee schedule,30.96,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,51.7,47,,21.92,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,64.63,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,51.7,47,,21.92,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,51.7,47,,21.92,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,30.68,115,,7.856,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,30.68,150,
MEDICAID UNITS 16-30,2200055,CDM,420,RC,97110,HCPCS,Outpatient,,,112.00,112.00,,65.8,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,65.8,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,54.22,48.41,,35.144,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,3.6,fee Schedule,100% of BCBS fee schedule,30.96,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,52.64,47,,34.12,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,65.8,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,52.64,47,,34.12,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,52.64,47,,34.12,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,30.68,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,7.144,Fee Schedule,115% of CMS OPPS Rate,30.68,150,
MEDICAID UNITS 31-45,2200056,CDM,420,RC,97110,HCPCS,Outpatient,,,152.00,152.00,,89.3,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.3,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.58,48.41,,11.664,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,3.6,fee Schedule,100% of BCBS fee schedule,30.96,100,,11.88,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,71.44,47,,11.32,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,11.88,Fee Schedule,100% of BCBS PPO fee schedule,89.3,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,71.44,47,,11.32,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,71.44,47,,11.32,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,30.68,115,,7.144,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,30.68,150,
MEDICAID UNITS 46-60,2200057,CDM,420,RC,97110,HCPCS,Outpatient,,,184.00,184.00,,108.1,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,108.1,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.07,48.41,,39.368,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,1.44,fee Schedule,100% of BCBS fee schedule,30.96,100,,14.4,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,86.48,47,,38.224,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,14.4,Fee Schedule,100% of BCBS PPO fee schedule,108.1,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,86.48,47,,38.224,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,86.48,47,,38.224,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,30.68,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,36.848,Fee Schedule,115% of CMS OPPS Rate,30.68,150,
G-CODE MOBILITY EVAL,2200058,CDM,420,RC,G8978,HCPCS,Outpatient,,,0.01,0.01,GP,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,150,
G-CODE MOBILITY INTERVAL,2200059,CDM,420,RC,G8979,HCPCS,Outpatient,,,0.01,0.01,GP,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,26.136,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,26.136,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,150,
G-CODE MOBILITY DISCHARGE,2200060,CDM,420,RC,G8980,HCPCS,Outpatient,,,0.01,0.01,CI,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,40.392,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,40.392,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,150,
G-CODE BODY POSITION EVAL,2200061,CDM,420,RC,G8981,HCPCS,Outpatient,,,0.01,0.01,GP,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,150,
G-CODE BODY POSITION INTERVAL,2200062,CDM,420,RC,G8982,HCPCS,Outpatient,,,0.01,0.01,GP,0.01,58.75,,77.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,77.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,77.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,150,
G-CODE BODY POSITION DISCHARGE,2200063,CDM,420,RC,G8983,HCPCS,Outpatient,,,0.01,0.01,GP,0.01,58.75,,89.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,89.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,89.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,150,
G-CODE CARRYING OBJECTS EVAL,2200064,CDM,420,RC,G8984,HCPCS,Outpatient,,,0.01,0.01,GP,0.01,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,150,
G-CODE CARRYING OBJ INTERVAL,2200065,CDM,420,RC,G8985,HCPCS,Outpatient,,,0.01,0.01,GP,0.01,58.75,,49.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,49.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,49.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,150,
G-CODE CARRYING OBJ DISCHARGE,2200066,CDM,420,RC,G8986,HCPCS,Outpatient,,,0.01,0.01,GP,0.01,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,150,
G-CODE SELF CARE EVAL,2200067,CDM,420,RC,G8987,HCPCS,Outpatient,,,0.01,0.01,GP,0.01,58.75,,63.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,63.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,63.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,150,
G-CODE SELF CARE INTERVAL,2200068,CDM,420,RC,G8988,HCPCS,Outpatient,,,0.01,0.01,GP,0.01,58.75,,68.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,68.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,68.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,150,
G-CODE SELF CARE DISCHARGE,2200069,CDM,420,RC,G8989,HCPCS,Outpatient,,,0.01,0.01,GP,0.01,58.75,,35.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,35.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,35.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,150,
G-CODE OTHER PT EVAL,2200070,CDM,420,RC,G8990,HCPCS,Outpatient,,,0.01,0.01,GP,0.01,58.75,,86.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,86.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,86.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,150,
G-CODE OTHER PT INTERVAL,2200071,CDM,420,RC,G8991,HCPCS,Outpatient,,,0.01,0.01,GP,0.01,58.75,,117.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,117.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,117.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,150,
G-CODE OTHER PT DISCHARGE,2200072,CDM,420,RC,G8992,HCPCS,Outpatient,,,0.01,0.01,GP,0.01,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,150,
G-CODE OTHER SUB EVAL,2200073,CDM,420,RC,G8993,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,86.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,86.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,86.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,150,
G-CODE OTHER SUB INTERVAL,2200074,CDM,420,RC,G8994,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,30.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,30.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,30.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,150,
G-CODE OTHER SUB DISCHARGE,2200075,CDM,420,RC,G8995,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,32.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,32.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,210.24,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,32.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,150,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,150,
PT EVAL MOD COMP 30 MIN,2200076,CDM,420,RC,97162,HCPCS,Outpatient,,,164.70,164.70,GP,96.76,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.76,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.73,48.41,,21.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,86.3,100,,10.08,fee Schedule,100% of BCBS fee schedule,86.3,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,77.41,47,,21.096,Percent of Total Billed Charges,47% of Total Billed Charges,86.3,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,96.76,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.41,47,,21.096,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,77.41,47,,21.096,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,104.43,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,104.43,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,77.41,150,
PT EVAL HIGH COMP 45 MIN,2200077,CDM,420,RC,97163,HCPCS,Outpatient,,,189.70,189.70,,111.45,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,111.45,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,91.83,48.41,,41.44,Percent of Total Billed Charges,48.41% of Total Billed Charges,86.3,100,,4.32,fee Schedule,100% of BCBS fee schedule,86.3,100,,10.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,89.16,47,,40.232,Percent of Total Billed Charges,47% of Total Billed Charges,86.3,100,,10.08,Fee Schedule,100% of BCBS PPO fee schedule,111.45,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,89.16,47,,40.232,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,89.16,47,,40.232,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,104.43,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,104.43,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,86.3,150,
OT EVAL INITIAL,2200078,CDM,430,RC,Q0109,HCPCS,Outpatient,,,126.00,126.00,,74.03,58.75,,27.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.03,58.75,,27.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,61,48.41,,20.528,Percent of Total Billed Charges,48.41% of Total Billed Charges,113.4,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,113.4,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,59.22,47,,19.928,Percent of Total Billed Charges,47% of Total Billed Charges,113.4,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,74.03,58.75,,27.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,59.22,47,,19.928,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,59.22,47,,19.928,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,59.22,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,59.22,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,59.22,113.4,
OT RE-EVAL,2200079,CDM,430,RC,97168,HCPCS,Outpatient,,,105.00,105.00,,61.69,58.75,,42.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.69,58.75,,42.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.83,48.41,,55.768,Percent of Total Billed Charges,48.41% of Total Billed Charges,62.71,100,,3.96,fee Schedule,100% of BCBS fee schedule,62.71,100,,41.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,49.35,47,,54.144,Percent of Total Billed Charges,47% of Total Billed Charges,62.71,100,,41.04,Fee Schedule,100% of BCBS PPO fee schedule,61.69,58.75,,42.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.35,47,,54.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,49.35,47,,54.144,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,73.39,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,73.39,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,49.35,90,
OT EVAL LOW COMPLEXITY,2200080,CDM,430,RC,97165,HCPCS,Outpatient,,,126.00,126.00,GO,74.03,58.75,,14.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.03,58.75,,14.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,61,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,91.33,100,,3.6,fee Schedule,100% of BCBS fee schedule,91.33,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,59.22,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,91.33,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,74.03,58.75,,14.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,59.22,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,59.22,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,107,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,107,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,59.22,107,
OT EVAL MODERATE COMPLEXITY,2200081,CDM,430,RC,97166,HCPCS,Outpatient,,,136.00,136.00,,79.9,58.75,,47.776,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.9,58.75,,47.776,Percent of Total Billed Charges,58.75% of Total Billed Charges,65.84,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,90.99,100,,3.6,fee Schedule,100% of BCBS fee schedule,90.99,100,,210.24,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,63.92,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,90.99,100,,210.24,Fee Schedule,100% of BCBS PPO fee schedule,79.9,58.75,,47.776,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,63.92,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,63.92,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,107,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,107,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,63.92,107,
OT EVAL HIGH COMPLEXITY,2200082,CDM,430,RC,97167,HCPCS,Outpatient,,,146.00,146.00,,85.78,58.75,,64.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,85.78,58.75,,64.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,70.68,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,90.99,100,,3.6,fee Schedule,100% of BCBS fee schedule,90.99,100,,10.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,68.62,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,90.99,100,,10.08,Fee Schedule,100% of BCBS PPO fee schedule,85.78,58.75,,64.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,68.62,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,68.62,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,107,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,107,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,68.62,107,
OT THER EX 1-15,2200083,CDM,430,RC,97110,HCPCS,Outpatient,,,76.00,76.00,GO,44.65,58.75,,78.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.65,58.75,,78.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.79,48.41,,8.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,3.6,fee Schedule,100% of BCBS fee schedule,30.96,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,35.72,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,44.65,58.75,,78.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.72,47,,7.896,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,35.72,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,5.264,Fee Schedule,115% of CMS OPPS Rate,30.68,90,
OT THER EX 16-30,2200084,CDM,430,RC,97110,HCPCS,Outpatient,,,183.90,183.90,GO,108.04,58.75,,15.936,Percent of Total Billed Charges,58.75% of Total Billed Charges,108.04,58.75,,15.936,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.03,48.41,,50.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,3.6,fee Schedule,100% of BCBS fee schedule,30.96,100,,10.8,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,86.43,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,10.8,Fee Schedule,100% of BCBS PPO fee schedule,108.04,58.75,,15.936,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,86.43,47,,48.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,86.43,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,30.68,115,,5.264,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,30.68,108.04,
OT THER EX 31-45,2200085,CDM,430,RC,97110,HCPCS,Outpatient,,,251.00,251.00,GO,147.46,58.75,,31.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,147.46,58.75,,31.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,121.51,48.41,,7.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,3.6,fee Schedule,100% of BCBS fee schedule,30.96,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,117.97,47,,6.92,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,147.46,58.75,,31.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,117.97,47,,6.92,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,117.97,47,,6.92,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,30.68,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,21.432,Fee Schedule,115% of CMS OPPS Rate,30.68,147.46,
OT HOT PACK-COLD PACK,2200086,CDM,430,RC,97110,HCPCS,Outpatient,,,130.00,130.00,GO,76.38,58.75,,39.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.38,58.75,,39.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.93,48.41,,4.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,4.32,fee Schedule,100% of BCBS fee schedule,30.96,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,61.1,47,,4.704,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,76.38,58.75,,39.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,61.1,47,,4.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,61.1,47,,4.704,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,30.68,115,,21.432,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.68,90,
OT DEBRIDE WOUND,2200087,CDM,430,RC,97597,HCPCS,Outpatient,,,183.90,183.90,,108.04,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,108.04,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.03,48.41,,21.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,167.75,100,,3.6,fee Schedule,100% of BCBS fee schedule,167.75,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,86.43,47,,21.304,Percent of Total Billed Charges,47% of Total Billed Charges,167.75,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,108.04,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,86.43,47,,21.304,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,86.43,47,,21.304,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,36.96,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,36.96,115,,109.792,Fee Schedule,115% of CMS OPPS Rate,36.96,167.75,
OT ULTRASOUND,2200088,CDM,430,RC,97035,HCPCS,Outpatient,,,64.25,64.25,,37.75,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.75,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.1,48.41,,14.448,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.57,100,,3.6,fee Schedule,100% of BCBS fee schedule,14.57,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,30.2,47,,14.032,Percent of Total Billed Charges,47% of Total Billed Charges,14.57,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,37.75,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.2,47,,14.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,30.2,47,,14.032,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,14.72,115,,109.792,Fee Schedule,115% of CMS OPPS Rate,14.72,115,,5.264,Fee Schedule,115% of CMS OPPS Rate,14.57,90,
OT PHONOPHORESIS,2200089,CDM,430,RC,97035,HCPCS,Outpatient,,,68.20,68.20,,40.07,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.07,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.02,48.41,,21.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.57,100,,253.44,fee Schedule,100% of BCBS fee schedule,14.57,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,32.05,47,,21.304,Percent of Total Billed Charges,47% of Total Billed Charges,14.57,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,40.07,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.05,47,,21.304,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,32.05,47,,21.304,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,14.72,115,,5.264,Fee Schedule,115% of CMS OPPS Rate,14.72,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,14.57,90,
OT PARAFFIN,2200090,CDM,430,RC,97018,HCPCS,Outpatient,,,51.00,51.00,,29.96,58.75,,29.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.96,58.75,,29.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.69,48.41,,20.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.84,100,,14.4,fee Schedule,100% of BCBS fee schedule,5.84,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,23.97,47,,20.024,Percent of Total Billed Charges,47% of Total Billed Charges,5.84,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,29.96,58.75,,29.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,20.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.97,47,,20.024,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,6.26,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,6.26,115,,5.64,Fee Schedule,115% of CMS OPPS Rate,5.84,90,
OT MASSAGE,2200091,CDM,430,RC,97124,HCPCS,Outpatient,,,57.00,57.00,,33.49,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.49,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.59,48.41,,26.08,Percent of Total Billed Charges,48.41% of Total Billed Charges,29.3,100,,23.76,fee Schedule,100% of BCBS fee schedule,29.3,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,26.79,47,,25.32,Percent of Total Billed Charges,47% of Total Billed Charges,29.3,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,33.49,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,25.32,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.79,47,,25.32,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,31.12,115,,5.64,Fee Schedule,115% of CMS OPPS Rate,31.12,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,26.79,90,
OT E-STIM,2200092,CDM,430,RC,97032,HCPCS,Outpatient,,,58.30,58.30,GO,34.25,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.25,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.22,48.41,,19.768,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.09,100,,159.84,fee Schedule,100% of BCBS fee schedule,15.09,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,27.4,47,,19.192,Percent of Total Billed Charges,47% of Total Billed Charges,15.09,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,34.25,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.4,47,,19.192,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,27.4,47,,19.192,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,15.25,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,15.25,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,15.09,90,
OT MEDICAID EVAL,2200093,CDM,430,RC,,,Outpatient,,,90.75,90.75,,53.32,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,53.32,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,43.93,48.41,,71.224,Percent of Total Billed Charges,48.41% of Total Billed Charges,81.68,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,81.68,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,42.65,47,,69.144,Percent of Total Billed Charges,47% of Total Billed Charges,81.68,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,53.32,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,42.65,47,,69.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,42.65,47,,69.144,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,42.65,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,42.65,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,42.65,90,
OT MEDICAID UNIT 1-15,2200094,CDM,430,RC,97110,HCPCS,Outpatient,,,30.11,30.11,,17.69,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.69,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.58,48.41,,109.056,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,9.36,fee Schedule,100% of BCBS fee schedule,30.96,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,14.15,47,,105.88,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,17.69,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.15,47,,105.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.15,47,,105.88,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,14.15,90,
OT MEDICAID UNIT 16-30,2200095,CDM,430,RC,97110,HCPCS,Outpatient,,,101.65,101.65,,59.72,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,59.72,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.21,48.41,,98.368,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,20.88,fee Schedule,100% of BCBS fee schedule,30.96,100,,253.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,47.78,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,253.44,Fee Schedule,100% of BCBS PPO fee schedule,59.72,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47.78,47,,95.504,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47.78,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.68,90,
OT MEDICAID UNIT 31-45,2200096,CDM,430,RC,97110,HCPCS,Outpatient,,,137.50,137.50,,80.78,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,80.78,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.56,48.41,,73.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,22.968,fee Schedule,100% of BCBS fee schedule,30.96,100,,14.4,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,64.63,47,,71.816,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,14.4,Fee Schedule,100% of BCBS PPO fee schedule,80.78,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,64.63,47,,71.816,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,64.63,47,,71.816,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.68,90,
OT MEDICAID UNITS 46-60,2200097,CDM,430,RC,97110,HCPCS,Outpatient,,,167.00,167.00,,98.11,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,98.11,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,80.84,48.41,,73.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,159.48,fee Schedule,100% of BCBS fee schedule,30.96,100,,23.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,78.49,47,,71.816,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,23.76,Fee Schedule,100% of BCBS PPO fee schedule,98.11,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,78.49,47,,71.816,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,78.49,47,,71.816,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.68,98.11,
OT MEDICAID UNITS PTA 1-15,2200098,CDM,430,RC,97110,HCPCS,Outpatient,,,33.90,33.90,,19.92,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.92,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.41,48.41,,89.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,47.52,fee Schedule,100% of BCBS fee schedule,30.96,100,,159.84,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,15.93,47,,86.48,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,159.84,Fee Schedule,100% of BCBS PPO fee schedule,19.92,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.93,47,,86.48,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.93,47,,86.48,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,15.93,90,
OT MEDICAID UNIT PTA 16-30,2200099,CDM,430,RC,97110,HCPCS,Outpatient,,,66.55,66.55,,39.1,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.1,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.22,48.41,,111.536,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,3.6,fee Schedule,100% of BCBS fee schedule,30.96,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,31.28,47,,108.288,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,39.1,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.28,47,,108.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.28,47,,108.288,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,30.68,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.68,90,
OT MEDICAID UNIT PTA 31-45,2200100,CDM,430,RC,97110,HCPCS,Outpatient,,,83.00,83.00,,48.76,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.76,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.18,48.41,,98.368,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,4.32,fee Schedule,100% of BCBS fee schedule,30.96,100,,9.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,39.01,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,9.36,Fee Schedule,100% of BCBS PPO fee schedule,48.76,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,39.01,47,,95.504,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,39.01,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.68,90,
OT MEDICAID UNIT PTA 46-60,2200101,CDM,430,RC,97110,HCPCS,Outpatient,,,100.00,100.00,,58.75,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.75,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.41,48.41,,111.536,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.96,100,,74.88,fee Schedule,100% of BCBS fee schedule,30.96,100,,20.88,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,47,47,,108.288,Percent of Total Billed Charges,47% of Total Billed Charges,30.96,100,,20.88,Fee Schedule,100% of BCBS PPO fee schedule,58.75,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47,47,,108.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47,47,,108.288,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,30.68,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.68,115,,132.352,Fee Schedule,115% of CMS OPPS Rate,30.68,90,
OT THERABAND,2200102,CDM,270,RC,99070,HCPCS,Outpatient,,,9.00,9.00,,5.29,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.29,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.36,48.41,,94.768,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.1,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,90,,22.968,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,47,,92.008,Percent of Total Billed Charges,47% of Total Billed Charges,8.1,90,,22.968,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,92.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.23,47,,92.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,8.1,
OT THERAPUTTY,2200103,CDM,270,RC,99070,HCPCS,Outpatient,,,17.00,17.00,,9.99,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,91.224,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,159.48,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,88.568,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,159.48,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,88.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,88.568,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
OT TRAPEEZE SET UP,2200104,CDM,430,RC,97799,HCPCS,Outpatient,,,62.00,62.00,,36.43,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.43,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.01,48.41,,95.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,55.8,90,,74.88,fee Schedule,90% of BCBS fee schedule,55.8,90,,47.52,Percent of Total Billed Charges,90% of Total Billed Charges,29.14,47,,92.368,Percent of Total Billed Charges,47% of Total Billed Charges,55.8,90,,47.52,Percent of Total Billed Charges,90% of Total Billed Charges,36.43,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.14,47,,92.368,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,29.14,47,,92.368,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,29.14,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,29.14,47,,83.472,Percent of Total Billed Charges,47% of Total Billed Charges,29.14,90,
OT TRAPEEZE RENTAL/DAY,2200105,CDM,430,RC,97799,HCPCS,Outpatient,,,13.00,13.00,,7.64,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,110.12,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,8.64,fee Schedule,90% of BCBS fee schedule,11.7,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,106.912,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,106.912,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,106.912,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,6.11,47,,83.472,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,90,
OT G CODE BODY POSITION DISCH,2200106,CDM,430,RC,G8983,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
OT G CODE BODY POSITION EVAL,2200107,CDM,430,RC,G8981,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,74.88,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,74.88,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
OT GCODE BODY POSITION INTRVAL,2200108,CDM,430,RC,G8982,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
OT G CODE CARRYING OBJ DISCH,2200109,CDM,430,RC,G8986,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,0.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
OT G CODE CARRYING OBJ INTERVL,2200110,CDM,430,RC,G8985,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,43.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,43.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,74.88,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,74.88,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,43.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
OT G CODE CARRYING OBJECT EVAL,2200111,CDM,430,RC,G8984,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,40.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,40.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,40.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
OT G CODE MOBILITY DISCHARGE,2200112,CDM,430,RC,G8980,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,39.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,39.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,39.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
OT G CODE MOBILITY EVAL,2200113,CDM,430,RC,G8978,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
OT G CODE MOBILITY INTERVAL,2200114,CDM,430,RC,G8979,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,37.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,37.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,37.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
OT G CODE OTHER DISCHARGE,2200115,CDM,430,RC,G8992,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,133.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,133.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,92.88,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,133.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
OT G CODE OTHER EVAL,2200116,CDM,430,RC,G8990,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,58.32,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
OT G CODE OTHER INTERVAL,2200117,CDM,430,RC,G8991,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,15.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,15.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,15.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
OT G CODE OTHER SUB DISCHARGE,2200118,CDM,430,RC,G8995,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,26.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,26.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,26.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
OT G CODE OTHER SUB EVAL,2200119,CDM,430,RC,G8993,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,50.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,50.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,50.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
OT G CODE OTHER SUB INTERVAL,2200120,CDM,430,RC,G8994,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,24.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,24.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,24.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
OT G CODE SELF CARE DISCHARGE,2200121,CDM,430,RC,G8989,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,67.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,67.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,92.88,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,92.88,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,67.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
OT G CODE SELF CARE EVAL,2200122,CDM,430,RC,G8987,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,58.32,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,58.32,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
OT G CODE SELF CARE INTERVAL,2200123,CDM,430,RC,G8988,HCPCS,Outpatient,,,0.01,0.01,,0.01,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.01,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,0.01,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,0.01,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.01,90,
OT ATTENDED WHIRLPOOL,2200124,CDM,430,RC,97022,HCPCS,Outpatient,,,93.00,93.00,,54.64,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,54.64,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.02,48.41,,64.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.75,100,,3.6,fee Schedule,100% of BCBS fee schedule,17.75,100,,10.8,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,43.71,47,,62.864,Percent of Total Billed Charges,47% of Total Billed Charges,17.75,100,,10.8,Fee Schedule,100% of BCBS PPO fee schedule,54.64,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,43.71,47,,62.864,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,43.71,47,,62.864,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,16.11,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,16.11,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,16.11,90,
OT BED MOBILITY/TRANSFER,2200125,CDM,430,RC,97530,HCPCS,Outpatient,,,85.20,85.20,,50.06,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.06,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.25,48.41,,73.272,Percent of Total Billed Charges,48.41% of Total Billed Charges,39.3,100,,4.32,fee Schedule,100% of BCBS fee schedule,39.3,100,,6.48,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,40.04,47,,71.136,Percent of Total Billed Charges,47% of Total Billed Charges,39.3,100,,6.48,Fee Schedule,100% of BCBS PPO fee schedule,50.06,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.04,47,,71.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.04,47,,71.136,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,36.39,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,36.39,115,,13.16,Fee Schedule,115% of CMS OPPS Rate,36.39,90,
OT BURN DEBRIDEMENT,2200126,CDM,430,RC,16020,HCPCS,Outpatient,,,85.00,85.00,,49.94,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.94,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.15,48.41,,91.768,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,59.04,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,39.95,47,,89.096,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,3.6,Fee Schedule,100% of ASC Tier Groupings,49.94,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,39.95,47,,89.096,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,39.95,47,,89.096,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,56.1,115,,13.16,Fee Schedule,115% of CMS OPPS Rate,56.1,115,,12.032,Fee Schedule,115% of CMS OPPS Rate,39.95,191.52,
OT CONTRAST BATH,2200127,CDM,430,RC,97034,HCPCS,Outpatient,,,79.00,79.00,,46.41,58.75,,8.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.41,58.75,,8.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.24,48.41,,29.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.25,100,,59.04,fee Schedule,100% of BCBS fee schedule,15.25,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,37.13,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,15.25,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,46.41,58.75,,8.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.13,47,,28.2,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,37.13,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,14.4,115,,12.032,Fee Schedule,115% of CMS OPPS Rate,14.4,115,,48.504,Fee Schedule,115% of CMS OPPS Rate,14.4,90,
OT DRESSING CHANGE LARGE,2200128,CDM,430,RC,97598,HCPCS,Outpatient,,,80.00,80.00,,47,58.75,,5.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,47,58.75,,5.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.73,48.41,,67.736,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37.6,47,,65.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,47,58.75,,5.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.6,47,,65.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,37.6,47,,65.76,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,25,115,,48.504,Fee Schedule,115% of CMS OPPS Rate,25,115,,30.456,Fee Schedule,115% of CMS OPPS Rate,25,90,
OT DRESSING CHANGE SMALL,2200129,CDM,430,RC,97597,HCPCS,Outpatient,,,283.00,283.00,,166.26,58.75,,26.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,166.26,58.75,,26.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,137,48.41,,70.288,Percent of Total Billed Charges,48.41% of Total Billed Charges,167.75,100,,4.32,fee Schedule,100% of BCBS fee schedule,167.75,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,133.01,47,,68.248,Percent of Total Billed Charges,47% of Total Billed Charges,167.75,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,166.26,58.75,,26.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,133.01,47,,68.248,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,133.01,47,,68.248,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,36.96,115,,30.456,Fee Schedule,115% of CMS OPPS Rate,36.96,115,,4.888,Fee Schedule,115% of CMS OPPS Rate,36.96,167.75,
OT ICE MASSAGE,2200130,CDM,430,RC,97799,HCPCS,Outpatient,,,38.00,38.00,,22.33,58.75,,17.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.33,58.75,,17.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.4,48.41,,63.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,34.2,90,,59.04,fee Schedule,90% of BCBS fee schedule,34.2,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,34.2,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,22.33,58.75,,17.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,62.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.86,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,17.86,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,90,
OT IONTOPHORESIS,2200131,CDM,430,RC,97033,HCPCS,Outpatient,,,34.00,34.00,,19.98,58.75,,26.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.98,58.75,,26.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.46,48.41,,63.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.84,100,,53.28,fee Schedule,100% of BCBS fee schedule,20.84,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,15.98,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,20.84,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,19.98,58.75,,26.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.98,47,,62.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.98,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,19.78,115,,5.64,Fee Schedule,115% of CMS OPPS Rate,19.78,115,,3.384,Fee Schedule,115% of CMS OPPS Rate,15.98,90,
OT MANUAL THERAPY,2200132,CDM,430,RC,97140,HCPCS,Outpatient,,,56.10,56.10,,32.96,58.75,,25.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.96,58.75,,25.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.16,48.41,,49.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.52,100,,3.6,fee Schedule,100% of BCBS fee schedule,28.52,100,,59.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,26.37,47,,47.752,Percent of Total Billed Charges,47% of Total Billed Charges,28.52,100,,59.04,Fee Schedule,100% of BCBS PPO fee schedule,32.96,58.75,,25.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.37,47,,47.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.37,47,,47.752,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,28.98,115,,3.384,Fee Schedule,115% of CMS OPPS Rate,28.98,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,26.37,90,
OT SHOULDER PULLEY,2200135,CDM,270,RC,99070,HCPCS,Outpatient,,,107.00,107.00,,62.86,58.75,,86.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.86,58.75,,86.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.8,48.41,,89.504,Percent of Total Billed Charges,48.41% of Total Billed Charges,96.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,96.3,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,50.29,47,,86.896,Percent of Total Billed Charges,47% of Total Billed Charges,96.3,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,62.86,58.75,,86.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,50.29,47,,86.896,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,50.29,47,,86.896,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,50.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,50.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,50.29,96.3,
OT WHIRLPOOL,2200136,CDM,430,RC,97022,HCPCS,Outpatient,,,53.00,53.00,,31.14,58.75,,132.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.14,58.75,,132.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.66,48.41,,181.248,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.75,100,,3.6,fee Schedule,100% of BCBS fee schedule,17.75,100,,59.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,24.91,47,,175.968,Percent of Total Billed Charges,47% of Total Billed Charges,17.75,100,,59.04,Fee Schedule,100% of BCBS PPO fee schedule,31.14,58.75,,132.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.91,47,,175.968,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,24.91,47,,175.968,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,16.11,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,16.11,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,16.11,90,
OT WHIRLPOOL STERILE,2200137,CDM,430,RC,97022,HCPCS,Outpatient,,,144.00,144.00,,84.6,58.75,,119.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.6,58.75,,119.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.71,48.41,,51.896,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.75,100,,12.96,fee Schedule,100% of BCBS fee schedule,17.75,100,,53.28,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,67.68,47,,50.384,Percent of Total Billed Charges,47% of Total Billed Charges,17.75,100,,53.28,Fee Schedule,100% of BCBS PPO fee schedule,84.6,58.75,,119.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,67.68,47,,50.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,67.68,47,,50.384,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,16.11,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,16.11,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,16.11,90,
STOCKINETTES SMALL,2200138,CDM,270,RC,99070,HCPCS,Outpatient,,,12.00,12.00,,7.05,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,213.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,207.552,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,207.552,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,207.552,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
STOCKINETTES MEDIUM,2200139,CDM,270,RC,99070,HCPCS,Outpatient,,,12.00,12.00,,7.05,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,77.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,62.784,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,75.072,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,75.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,75.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
STOCKINETTES LARGE,2200140,CDM,270,RC,99070,HCPCS,Outpatient,,,12.00,12.00,,7.05,58.75,,108.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,108.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,73.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,71.816,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,108.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,71.816,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,71.816,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
STOCKINETTES XL,2200141,CDM,270,RC,99070,HCPCS,Outpatient,,,21.00,21.00,,12.34,58.75,,135.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.34,58.75,,135.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.17,48.41,,71.232,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.9,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,18.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,47,,69.152,Percent of Total Billed Charges,47% of Total Billed Charges,18.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,12.34,58.75,,135.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.87,47,,69.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.87,47,,69.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.87,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,18.9,
K T TAPING,2200142,CDM,420,RC,,,Outpatient,,,130.00,130.00,,76.38,58.75,,119.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.38,58.75,,119.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.93,48.41,,238.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,117,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,117,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,61.1,47,,231.992,Percent of Total Billed Charges,47% of Total Billed Charges,117,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,76.38,58.75,,119.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,61.1,47,,231.992,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,61.1,47,,231.992,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,61.1,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,61.1,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,61.1,150,
SHOEHORN,2200143,CDM,270,RC,99070,HCPCS,Outpatient,,,18.40,18.40,,10.81,58.75,,135.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.81,58.75,,135.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.91,48.41,,73.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.56,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,16.56,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,8.65,47,,71.816,Percent of Total Billed Charges,47% of Total Billed Charges,16.56,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,10.81,58.75,,135.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.65,47,,71.816,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.65,47,,71.816,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.65,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,8.65,47,,27.824,Percent of Total Billed Charges,47% of Total Billed Charges,8.65,16.56,
PISTOL GRIP REACHER,2200144,CDM,270,RC,99070,HCPCS,Outpatient,,,12.50,12.50,,7.34,58.75,,115.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.34,58.75,,115.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.05,48.41,,44.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.25,90,,43.56,Percent of Total Billed Charges,90% of Total Billed Charges,11.25,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,5.88,47,,42.864,Percent of Total Billed Charges,47% of Total Billed Charges,11.25,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,7.34,58.75,,115.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.88,47,,42.864,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.88,47,,42.864,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.88,47,,27.824,Percent of Total Billed Charges,47% of Total Billed Charges,5.88,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.88,11.25,
NEUROMUSCULAR RE-EDUCATION,2200145,CDM,430,RC,97112,HCPCS,Outpatient,,,56.65,56.65,,33.28,58.75,,110.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.28,58.75,,110.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.42,48.41,,116.304,Percent of Total Billed Charges,48.41% of Total Billed Charges,35.55,100,,19.44,fee Schedule,100% of BCBS fee schedule,35.55,100,,62.784,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,26.63,47,,112.912,Percent of Total Billed Charges,47% of Total Billed Charges,35.55,100,,62.784,Fee Schedule,100% of BCBS PPO fee schedule,33.28,58.75,,110.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.63,47,,112.912,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.63,47,,112.912,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,34.14,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,34.14,115,,4.136,Fee Schedule,115% of CMS OPPS Rate,26.63,90,
COTA Medicaid Unit,2200146,CDM,430,RC,97530,HCPCS,Outpatient,,,37.31,37.31,,21.92,58.75,,115.456,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.92,58.75,,115.456,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.06,48.41,,61.576,Percent of Total Billed Charges,48.41% of Total Billed Charges,39.3,100,,5.04,fee Schedule,100% of BCBS fee schedule,39.3,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,17.54,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,39.3,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,21.92,58.75,,115.456,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.54,47,,59.784,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.54,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,36.39,115,,4.136,Fee Schedule,115% of CMS OPPS Rate,36.39,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,17.54,90,
NEUROMUSCULAR RE-EDUCATION,2200150,CDM,420,RC,97112,HCPCS,Outpatient,,,56.65,56.65,,33.28,58.75,,133.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.28,58.75,,133.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.42,48.41,,201.384,Percent of Total Billed Charges,48.41% of Total Billed Charges,35.55,100,,3.6,fee Schedule,100% of BCBS fee schedule,35.55,100,,26.64,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,26.63,47,,195.52,Percent of Total Billed Charges,47% of Total Billed Charges,35.55,100,,26.64,Fee Schedule,100% of BCBS PPO fee schedule,33.28,58.75,,133.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.63,47,,195.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.63,47,,195.52,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,34.14,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,34.14,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,26.63,150,
WHEELCHAIR MANAGEMENT TRAINING,2200151,CDM,420,RC,97542,HCPCS,Outpatient,,,53.25,53.25,,31.28,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.28,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.78,48.41,,135.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,33.45,100,,42.48,fee Schedule,100% of BCBS fee schedule,33.45,100,,23.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,25.03,47,,131.6,Percent of Total Billed Charges,47% of Total Billed Charges,33.45,100,,23.04,Fee Schedule,100% of BCBS PPO fee schedule,31.28,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,25.03,47,,131.6,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,25.03,47,,131.6,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,32.76,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,32.76,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,25.03,150,
KIDS MEDICAID EVAL (OT),2200152,CDM,430,RC,97166,HCPCS,Outpatient,,,67.34,67.34,,39.56,58.75,,86.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.56,58.75,,86.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.6,48.41,,123.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,90.99,100,,10.8,fee Schedule,100% of BCBS fee schedule,90.99,100,,21.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,31.65,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,90.99,100,,21.6,Fee Schedule,100% of BCBS PPO fee schedule,39.56,58.75,,86.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.65,47,,119.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.65,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,107,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,107,115,,6.768,Fee Schedule,115% of CMS OPPS Rate,31.65,107,
KIDS MEDICAID EVAL (ST),2200153,CDM,440,RC,92523,HCPCS,Outpatient,,,51.05,51.05,,29.99,58.75,,132.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.99,58.75,,132.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.71,48.41,,172.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,196.67,100,,10.8,fee Schedule,100% of BCBS fee schedule,196.67,100,,43.56,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,23.99,47,,167.32,Percent of Total Billed Charges,47% of Total Billed Charges,196.67,100,,43.56,Fee Schedule,100% of BCBS PPO fee schedule,29.99,58.75,,132.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.99,47,,167.32,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.99,47,,167.32,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,239.78,115,,6.768,Fee Schedule,115% of CMS OPPS Rate,239.78,115,,4.136,Fee Schedule,115% of CMS OPPS Rate,23.99,239.78,
DEBRIDE WOUND,2220063,CDM,420,RC,97597,HCPCS,Outpatient,,,183.90,183.90,,108.04,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,108.04,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.03,48.41,,206.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,167.75,100,,19.44,fee Schedule,100% of BCBS fee schedule,167.75,100,,19.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,86.43,47,,200.408,Percent of Total Billed Charges,47% of Total Billed Charges,167.75,100,,19.44,Fee Schedule,100% of BCBS PPO fee schedule,108.04,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,86.43,47,,200.408,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,86.43,47,,200.408,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,36.96,115,,4.136,Fee Schedule,115% of CMS OPPS Rate,36.96,115,,32.784,Fee Schedule,115% of CMS OPPS Rate,36.96,167.75,
MANDIBLE 4+ VIEWS,3010003,CDM,320,RC,70110,HCPCS,Outpatient,,,281.60,281.60,,165.44,58.75,,107.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,165.44,58.75,,107.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,136.32,48.41,,206.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,104.4,fee Schedule,100% of BCBS fee schedule,107.6,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,132.35,47,,200.784,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,165.44,58.75,,107.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,132.35,47,,200.784,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,132.35,47,,200.784,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,42.95,115,,32.784,Fee Schedule,115% of CMS OPPS Rate,42.95,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,42.95,284.64,
MASTIOD-4,3010006,CDM,320,RC,70130,HCPCS,Outpatient,,,254.00,254.00,,149.23,58.75,,132.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,149.23,58.75,,132.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,122.96,48.41,,262.192,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,20.88,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,119.38,47,,254.552,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,149.23,58.75,,132.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,119.38,47,,254.552,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,119.38,47,,254.552,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,61.2,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,61.2,115,,13.912,Fee Schedule,115% of CMS OPPS Rate,61.2,284.64,
FACIAL BONE 3 VW,3010012,CDM,320,RC,70150,HCPCS,Outpatient,,,191.00,191.00,,112.21,58.75,,86.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,112.21,58.75,,86.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,92.46,48.41,,216.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,12.96,fee Schedule,100% of BCBS fee schedule,107.6,100,,42.48,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,89.77,47,,210.184,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,42.48,Fee Schedule,100% of BCBS PPO fee schedule,112.21,58.75,,86.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,89.77,47,,210.184,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,89.77,47,,210.184,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,45.89,115,,13.912,Fee Schedule,115% of CMS OPPS Rate,45.89,115,,12.032,Fee Schedule,115% of CMS OPPS Rate,45.89,284.64,
NASAL BONE-3,3010016,CDM,320,RC,70160,HCPCS,Outpatient,,,191.00,191.00,,112.21,58.75,,77.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,112.21,58.75,,77.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,92.46,48.41,,227.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,10.8,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,89.77,47,,220.864,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,10.8,Fee Schedule,100% of BCBS PPO fee schedule,112.21,58.75,,77.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,89.77,47,,220.864,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,89.77,47,,220.864,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,36.78,115,,12.032,Fee Schedule,115% of CMS OPPS Rate,36.78,115,,11.28,Fee Schedule,115% of CMS OPPS Rate,36.78,211.49,
ORBITS 4 VIEWS,3010021,CDM,320,RC,70200,HCPCS,Outpatient,,,230.00,230.00,,135.13,58.75,,84.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,135.13,58.75,,84.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,111.34,48.41,,123.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.96,fee Schedule,100% of BCBS fee schedule,107.6,100,,10.8,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,108.1,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,10.8,Fee Schedule,100% of BCBS PPO fee schedule,135.13,58.75,,84.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,108.1,47,,119.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,108.1,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,46.94,115,,11.28,Fee Schedule,115% of CMS OPPS Rate,46.94,115,,22.752,Fee Schedule,115% of CMS OPPS Rate,46.94,284.64,
PARANASAL SIN 3VW,3010026,CDM,320,RC,70220,HCPCS,Outpatient,,,288.00,288.00,,169.2,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,169.2,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,139.42,48.41,,295.104,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,239.76,fee Schedule,100% of BCBS fee schedule,76.62,100,,19.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,135.36,47,,286.512,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,19.44,Fee Schedule,100% of BCBS PPO fee schedule,169.2,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,135.36,47,,286.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,135.36,47,,286.512,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,37.03,115,,22.752,Fee Schedule,115% of CMS OPPS Rate,37.03,115,,10.152,Fee Schedule,115% of CMS OPPS Rate,37.03,211.49,
SKULL 3 VIEWS,3010030,CDM,320,RC,70250,HCPCS,Outpatient,,,254.00,254.00,,149.23,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,149.23,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,122.96,48.41,,206.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,74.16,fee Schedule,100% of BCBS fee schedule,107.6,100,,104.4,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,119.38,47,,200.6,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,104.4,Fee Schedule,100% of BCBS PPO fee schedule,149.23,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,119.38,47,,200.6,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,119.38,47,,200.6,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,35.22,115,,10.152,Fee Schedule,115% of CMS OPPS Rate,35.22,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,35.22,284.64,
SKULL 4 VWS,3010033,CDM,320,RC,70260,HCPCS,Outpatient,,,288.00,288.00,,169.2,58.75,,94,Percent of Total Billed Charges,58.75% of Total Billed Charges,169.2,58.75,,94,Percent of Total Billed Charges,58.75% of Total Billed Charges,139.42,48.41,,207.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,264.24,fee Schedule,100% of BCBS fee schedule,107.6,100,,20.88,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,135.36,47,,201.912,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,20.88,Fee Schedule,100% of BCBS PPO fee schedule,169.2,58.75,,94,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,135.36,47,,201.912,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,135.36,47,,201.912,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,44.07,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,44.07,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,44.07,284.64,
CHEST 1 VIEW,3010040,CDM,320,RC,71045,HCPCS,Outpatient,,,244.70,244.70,,143.76,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,143.76,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,118.46,48.41,,88.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,12.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,115.01,47,,85.992,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,12.96,Fee Schedule,100% of BCBS PPO fee schedule,143.76,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.65,100,,,Fee Schedule,100% of ASC Tier Groupings,115.01,47,,85.992,Percent of Total Billed Charges,47% of Total Billed charges,13.65,100,,,Fee Schedule,100% ASC Tier Groupings,115.01,47,,85.992,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,25.63,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,25.63,115,,22.184,Fee Schedule,115% of CMS OPPS Rate,13.65,211.49,
CHEST 2 VIEWS,3010041,CDM,320,RC,71046,HCPCS,Outpatient,,,235.55,235.55,,138.39,58.75,,113.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,138.39,58.75,,113.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,114.03,48.41,,97.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,110.71,47,,94.752,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,138.39,58.75,,113.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.57,100,,,Fee Schedule,100% of ASC Tier Groupings,110.71,47,,94.752,Percent of Total Billed Charges,47% of Total Billed charges,18.57,100,,,Fee Schedule,100% ASC Tier Groupings,110.71,47,,94.752,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,33.2,115,,22.184,Fee Schedule,115% of CMS OPPS Rate,33.2,115,,5.64,Fee Schedule,115% of CMS OPPS Rate,18.57,211.49,
RIBS UNILAT 3 VW,3010049,CDM,320,RC,71101,HCPCS,Outpatient,,,245.65,245.65,,144.32,58.75,,78.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,144.32,58.75,,78.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,118.92,48.41,,123.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,115.46,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,144.32,58.75,,78.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,115.46,47,,119.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,115.46,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,41.46,115,,5.64,Fee Schedule,115% of CMS OPPS Rate,41.46,115,,5.64,Fee Schedule,115% of CMS OPPS Rate,41.46,284.64,
RIBS BILAT 4 VW,3010051,CDM,320,RC,71111,HCPCS,Outpatient,,,284.35,284.35,,167.06,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,167.06,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,137.65,48.41,,221.528,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,239.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,133.64,47,,215.072,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,239.76,Fee Schedule,100% of BCBS PPO fee schedule,167.06,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,133.64,47,,215.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,133.64,47,,215.072,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,51.51,115,,5.64,Fee Schedule,115% of CMS OPPS Rate,51.51,115,,10.152,Fee Schedule,115% of CMS OPPS Rate,51.51,284.64,
STERNUM MIN 2 VIEWS,3010052,CDM,320,RC,71120,HCPCS,Outpatient,,,165.00,165.00,,96.94,58.75,,82.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.94,58.75,,82.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.88,48.41,,104.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,70.56,fee Schedule,100% of BCBS fee schedule,76.62,100,,74.16,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,77.55,47,,101.52,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,74.16,Fee Schedule,100% of BCBS PPO fee schedule,96.94,58.75,,82.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.55,47,,101.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,77.55,47,,101.52,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,32.78,115,,10.152,Fee Schedule,115% of CMS OPPS Rate,32.78,115,,54.52,Fee Schedule,115% of CMS OPPS Rate,32.78,211.49,
SPINE CERV 2-3 VIEW,3010054,CDM,320,RC,72040,HCPCS,Outpatient,,,183.40,183.40,,107.75,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,107.75,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,88.78,48.41,,98.368,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,5.04,fee Schedule,100% of BCBS fee schedule,76.62,100,,264.24,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,86.2,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,264.24,Fee Schedule,100% of BCBS PPO fee schedule,107.75,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,86.2,47,,95.504,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,86.2,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,38.95,115,,54.52,Fee Schedule,115% of CMS OPPS Rate,38.95,115,,10.904,Fee Schedule,115% of CMS OPPS Rate,38.95,211.49,
SPINE CERV 4+ VIEWS,3010058,CDM,320,RC,72050,HCPCS,Outpatient,,,281.60,281.60,,165.44,58.75,,78.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,165.44,58.75,,78.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,136.32,48.41,,123.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,51.12,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,132.35,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,165.44,58.75,,78.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,132.35,47,,119.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,132.35,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,52.97,115,,10.904,Fee Schedule,115% of CMS OPPS Rate,52.97,115,,6.768,Fee Schedule,115% of CMS OPPS Rate,52.97,284.64,
SPIN THORACIC-2,3010062,CDM,320,RC,72070,HCPCS,Outpatient,,,181.50,181.50,,106.63,58.75,,88.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,106.63,58.75,,88.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,87.86,48.41,,123.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,51.12,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,85.31,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,106.63,58.75,,88.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,85.31,47,,119.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,85.31,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,32.45,115,,6.768,Fee Schedule,115% of CMS OPPS Rate,32.45,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,32.45,284.64,
SPINE LUM 2-3 VIEW,3010068,CDM,320,RC,72100,HCPCS,Outpatient,,,228.95,228.95,,134.51,58.75,,111.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,134.51,58.75,,111.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,110.83,48.41,,123.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,9.36,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,107.61,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,134.51,58.75,,111.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,107.61,47,,119.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,107.61,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,38.95,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,38.95,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,38.95,284.64,
SPINE LUMBAR 4+VIEW,3010069,CDM,320,RC,72110,HCPCS,Outpatient,,,281.60,281.60,,165.44,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,165.44,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,136.32,48.41,,206.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,9.36,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,132.35,47,,200.408,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,165.44,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,132.35,47,,200.408,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,132.35,47,,200.408,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,51,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,51,115,,125.208,Fee Schedule,115% of CMS OPPS Rate,51,284.64,
PELVIS 1 OR 2 VIEW,3010071,CDM,320,RC,72170,HCPCS,Outpatient,,,183.90,183.90,,108.04,58.75,,82.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,108.04,58.75,,82.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.03,48.41,,187.832,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,128.16,fee Schedule,100% of BCBS fee schedule,107.6,100,,70.56,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,86.43,47,,182.36,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,70.56,Fee Schedule,100% of BCBS PPO fee schedule,108.04,58.75,,82.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,86.43,47,,182.36,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,86.43,47,,182.36,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,27.5,115,,125.208,Fee Schedule,115% of CMS OPPS Rate,27.5,115,,38.728,Fee Schedule,115% of CMS OPPS Rate,27.5,284.64,
SAC-IL JNTS-3,3010073,CDM,320,RC,72202,HCPCS,Outpatient,,,164.00,164.00,,96.35,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.35,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.39,48.41,,123.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,151.92,fee Schedule,100% of BCBS fee schedule,107.6,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,77.08,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,96.35,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.08,47,,119.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,77.08,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,38.69,115,,38.728,Fee Schedule,115% of CMS OPPS Rate,38.69,115,,137.992,Fee Schedule,115% of CMS OPPS Rate,38.69,284.64,
SACRUM 2 VIEWS,3010074,CDM,320,RC,72220,HCPCS,Outpatient,,,180.40,180.40,,105.99,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,105.99,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,87.33,48.41,,145.232,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,15.84,fee Schedule,100% of BCBS fee schedule,76.62,100,,51.12,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,84.79,47,,141,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,51.12,Fee Schedule,100% of BCBS PPO fee schedule,105.99,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,84.79,47,,141,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,84.79,47,,141,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,31.98,115,,137.992,Fee Schedule,115% of CMS OPPS Rate,31.98,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,31.98,211.49,
SHOULDER MIN 2VRIGH,3010077,CDM,320,RC,73030,HCPCS,Outpatient,,,165.00,165.00,RT,96.94,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.94,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.88,48.41,,91.376,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,16.56,fee Schedule,100% of BCBS fee schedule,76.62,100,,51.12,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,77.55,47,,88.72,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,51.12,Fee Schedule,100% of BCBS PPO fee schedule,96.94,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.55,47,,88.72,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,77.55,47,,88.72,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,33.95,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,33.95,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,33.95,211.49,
CLAVICLE 2 VIEWS,3010080,CDM,320,RC,73000,HCPCS,Outpatient,,,152.00,152.00,,89.3,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.3,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.58,48.41,,104.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,9.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,71.44,47,,101.52,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,9.36,Fee Schedule,100% of BCBS PPO fee schedule,89.3,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,71.44,47,,101.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,71.44,47,,101.52,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,31.92,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,31.92,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,31.92,211.49,
SCAPUL UNI 2 VW,3010081,CDM,320,RC,73010,HCPCS,Outpatient,,,200.00,200.00,,117.5,58.75,,78.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,117.5,58.75,,78.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.82,48.41,,123.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,259.2,fee Schedule,100% of BCBS fee schedule,107.6,100,,9.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,94,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,9.36,Fee Schedule,100% of BCBS PPO fee schedule,117.5,58.75,,78.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,94,47,,119.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,94,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,23.66,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,23.66,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,23.66,284.64,
ACROM CLAV JT-2,3010086,CDM,320,RC,73050,HCPCS,Outpatient,,,152.00,152.00,,89.3,58.75,,109.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.3,58.75,,109.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.58,48.41,,115.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,55.44,fee Schedule,100% of BCBS fee schedule,76.62,100,,128.16,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,71.44,47,,112.048,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,128.16,Fee Schedule,100% of BCBS PPO fee schedule,89.3,58.75,,109.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,71.44,47,,112.048,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,71.44,47,,112.048,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,28.51,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,28.51,115,,36.848,Fee Schedule,115% of CMS OPPS Rate,28.51,211.49,
HUMEROUS MIN 2 V RT,3010087,CDM,320,RC,73060,HCPCS,Outpatient,,,242.00,242.00,RT,142.18,58.75,,108.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,142.18,58.75,,108.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,117.15,48.41,,123.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,10.8,fee Schedule,100% of BCBS fee schedule,76.62,100,,151.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,113.74,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,151.92,Fee Schedule,100% of BCBS PPO fee schedule,142.18,58.75,,108.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,113.74,47,,119.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,113.74,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,31.28,115,,36.848,Fee Schedule,115% of CMS OPPS Rate,31.28,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,31.28,211.49,
ELBOW 2 VIEWS RIGHT,3010088,CDM,320,RC,73070,HCPCS,Outpatient,,,167.50,167.50,RT,98.41,58.75,,219.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,98.41,58.75,,219.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,81.09,48.41,,66.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,19.44,fee Schedule,100% of BCBS fee schedule,76.62,100,,15.84,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,78.73,47,,64.672,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,15.84,Fee Schedule,100% of BCBS PPO fee schedule,98.41,58.75,,219.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,78.73,47,,64.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,78.73,47,,64.672,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,28.73,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,28.73,115,,26.696,Fee Schedule,115% of CMS OPPS Rate,28.73,211.49,
RAD & ULNA 2 VWRT,3010091,CDM,320,RC,73090,HCPCS,Outpatient,,,181.50,181.50,RT,106.63,58.75,,62.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,106.63,58.75,,62.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,87.86,48.41,,376.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,23.04,fee Schedule,100% of BCBS fee schedule,76.62,100,,16.56,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,85.31,47,,365.096,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,16.56,Fee Schedule,100% of BCBS PPO fee schedule,106.63,58.75,,62.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,85.31,47,,365.096,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,85.31,47,,365.096,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,28.73,115,,26.696,Fee Schedule,115% of CMS OPPS Rate,28.73,115,,26.696,Fee Schedule,115% of CMS OPPS Rate,28.73,211.49,
WRIST 3 VIEWS RIGHT,3010092,CDM,320,RC,73110,HCPCS,Outpatient,,,174.90,174.90,RT,102.75,58.75,,259.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,102.75,58.75,,259.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.67,48.41,,145.272,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,21.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,82.2,47,,141.04,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,102.75,58.75,,259.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,82.2,47,,141.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,82.2,47,,141.04,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,40.3,115,,26.696,Fee Schedule,115% of CMS OPPS Rate,40.3,115,,4.888,Fee Schedule,115% of CMS OPPS Rate,40.3,211.49,
HAND 3 VIEWS RIGHT,3010097,CDM,320,RC,73130,HCPCS,Outpatient,,,159.00,159.00,RT,93.41,58.75,,93.832,Percent of Total Billed Charges,58.75% of Total Billed Charges,93.41,58.75,,93.832,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.97,48.41,,178.92,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,14.4,fee Schedule,100% of BCBS fee schedule,76.62,100,,259.2,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,74.73,47,,173.712,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,259.2,Fee Schedule,100% of BCBS PPO fee schedule,93.41,58.75,,93.832,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,74.73,47,,173.712,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,74.73,47,,173.712,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,36.46,115,,4.888,Fee Schedule,115% of CMS OPPS Rate,36.46,115,,4.888,Fee Schedule,115% of CMS OPPS Rate,36.46,211.49,
FINGER 2 + VIEWS,3010100,CDM,320,RC,73140,HCPCS,Outpatient,,,167.20,167.20,,98.23,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,98.23,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,80.94,48.41,,402.768,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,26.64,fee Schedule,100% of BCBS fee schedule,76.62,100,,55.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,78.58,47,,391.04,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,55.44,Fee Schedule,100% of BCBS PPO fee schedule,98.23,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,78.58,47,,391.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,78.58,47,,391.04,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,37.2,115,,4.888,Fee Schedule,115% of CMS OPPS Rate,37.2,115,,66.928,Fee Schedule,115% of CMS OPPS Rate,37.2,211.49,
HIP UNI 2 VW,3010102,CDM,320,RC,73502,HCPCS,Outpatient,,,189.20,189.20,,111.16,58.75,,86.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,111.16,58.75,,86.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,91.59,48.41,,118.12,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,6.48,fee Schedule,100% of BCBS fee schedule,76.62,100,,10.8,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,88.92,47,,114.68,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,10.8,Fee Schedule,100% of BCBS PPO fee schedule,111.16,58.75,,86.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,88.92,47,,114.68,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,88.92,47,,114.68,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,46.63,115,,66.928,Fee Schedule,115% of CMS OPPS Rate,46.63,115,,79.336,Fee Schedule,115% of CMS OPPS Rate,46.63,211.49,
HIP BILAT 2 VW,3010104,CDM,320,RC,73521,HCPCS,Outpatient,,,236.95,236.95,,139.21,58.75,,289.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,139.21,58.75,,289.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,114.71,48.41,,123.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,16.56,fee Schedule,100% of BCBS fee schedule,107.6,100,,19.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,111.37,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,19.44,Fee Schedule,100% of BCBS PPO fee schedule,139.21,58.75,,289.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,111.37,47,,119.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,111.37,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,40.55,115,,79.336,Fee Schedule,115% of CMS OPPS Rate,40.55,115,,8.272,Fee Schedule,115% of CMS OPPS Rate,40.55,284.64,
FEMUR 1 VIEW,3010108,CDM,320,RC,73551,HCPCS,Outpatient,,,75.00,75.00,,44.06,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.06,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.31,48.41,,146.008,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,115.2,fee Schedule,100% of BCBS fee schedule,76.62,100,,23.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,35.25,47,,141.752,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,23.04,Fee Schedule,100% of BCBS PPO fee schedule,44.06,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.25,47,,141.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,35.25,47,,141.752,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,29.05,115,,8.272,Fee Schedule,115% of CMS OPPS Rate,29.05,115,,8.648,Fee Schedule,115% of CMS OPPS Rate,29.05,211.49,
KNEE 1 OR 2 VIEWS RT,3010110,CDM,320,RC,73560,HCPCS,Outpatient,,,174.90,174.90,RT,102.75,58.75,,53.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,102.75,58.75,,53.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.67,48.41,,217.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,16.56,fee Schedule,100% of BCBS fee schedule,76.62,100,,21.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,82.2,47,,210.936,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,21.6,Fee Schedule,100% of BCBS PPO fee schedule,102.75,58.75,,53.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,82.2,47,,210.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,82.2,47,,210.936,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,33.2,115,,8.648,Fee Schedule,115% of CMS OPPS Rate,33.2,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,33.2,211.49,
TIB/FIB 2 VW RIGHT,3010114,CDM,320,RC,73590,HCPCS,Outpatient,,,181.50,181.50,RT,106.63,58.75,,141.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,106.63,58.75,,141.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,87.86,48.41,,51.544,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,61.2,fee Schedule,100% of BCBS fee schedule,76.62,100,,14.4,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,85.31,47,,50.048,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,14.4,Fee Schedule,100% of BCBS PPO fee schedule,106.63,58.75,,141.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,85.31,47,,50.048,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,85.31,47,,50.048,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,30.97,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.97,115,,135.36,Fee Schedule,115% of CMS OPPS Rate,30.97,211.49,
ANKLE 3 VIEWS RIGHT,3010117,CDM,320,RC,73610,HCPCS,Outpatient,,,165.00,165.00,RT,96.94,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.94,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.88,48.41,,70.288,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,12.24,fee Schedule,100% of BCBS fee schedule,76.62,100,,26.64,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,77.55,47,,68.248,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,26.64,Fee Schedule,100% of BCBS PPO fee schedule,96.94,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.55,47,,68.248,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,77.55,47,,68.248,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,35.5,115,,135.36,Fee Schedule,115% of CMS OPPS Rate,35.5,115,,28.952,Fee Schedule,115% of CMS OPPS Rate,35.5,211.49,
FOOT RAD 3 VW RIGHT,3010122,CDM,320,RC,73630,HCPCS,Outpatient,,,165.00,165.00,RT,96.94,58.75,,244.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.94,58.75,,244.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.88,48.41,,70.288,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,9.36,fee Schedule,100% of BCBS fee schedule,76.62,100,,6.48,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,77.55,47,,68.248,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,6.48,Fee Schedule,100% of BCBS PPO fee schedule,96.94,58.75,,244.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.55,47,,68.248,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,77.55,47,,68.248,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,33.26,115,,28.952,Fee Schedule,115% of CMS OPPS Rate,33.26,115,,5.64,Fee Schedule,115% of CMS OPPS Rate,33.26,211.49,
CALCANEUS 2 VIEWS RT,3010124,CDM,320,RC,73650,HCPCS,Outpatient,,,127.00,127.00,RT,74.61,58.75,,164.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.61,58.75,,164.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.48,48.41,,71.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,16.56,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,59.69,47,,69.28,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,16.56,Fee Schedule,100% of BCBS PPO fee schedule,74.61,58.75,,164.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,59.69,47,,69.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,59.69,47,,69.28,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,27.76,115,,5.64,Fee Schedule,115% of CMS OPPS Rate,27.76,115,,10.152,Fee Schedule,115% of CMS OPPS Rate,27.76,211.49,
TOES 2 VIEWS,3010125,CDM,320,RC,73660,HCPCS,Outpatient,,,167.00,167.00,,98.11,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,98.11,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,80.84,48.41,,73.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,115.2,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,78.49,47,,71.816,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,115.2,Fee Schedule,100% of BCBS PPO fee schedule,98.11,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,78.49,47,,71.816,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,78.49,47,,71.816,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,28.24,115,,10.152,Fee Schedule,115% of CMS OPPS Rate,28.24,115,,12.032,Fee Schedule,115% of CMS OPPS Rate,28.24,211.49,
ABDOMEN 1 VIEW,3010126,CDM,320,RC,74018,HCPCS,Outpatient,,,232.95,232.95,,136.86,58.75,,209.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,136.86,58.75,,209.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,112.77,48.41,,63.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,16.56,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,109.49,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,16.56,Fee Schedule,100% of BCBS PPO fee schedule,136.86,58.75,,209.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,109.49,47,,62.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,109.49,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,29.47,115,,12.032,Fee Schedule,115% of CMS OPPS Rate,29.47,115,,11.28,Fee Schedule,115% of CMS OPPS Rate,29.47,211.49,
ABDOMEN 2 VIEWS,3010127,CDM,320,RC,74019,HCPCS,Outpatient,,,231.10,231.10,,135.77,58.75,,250.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,135.77,58.75,,250.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,111.88,48.41,,64.672,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,196.56,fee Schedule,100% of BCBS fee schedule,107.6,100,,61.2,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,108.62,47,,62.792,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,61.2,Fee Schedule,100% of BCBS PPO fee schedule,135.77,58.75,,250.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,108.62,47,,62.792,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,108.62,47,,62.792,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,36.44,115,,11.28,Fee Schedule,115% of CMS OPPS Rate,36.44,115,,7.52,Fee Schedule,115% of CMS OPPS Rate,36.44,284.64,
SM BOWEL SERIES-4,3010138,CDM,320,RC,74245,HCPCS,Outpatient,,,468.00,468.00,,274.95,58.75,,250.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,274.95,58.75,,250.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,226.56,48.41,,61.576,Percent of Total Billed Charges,48.41% of Total Billed Charges,421.2,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,421.2,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,219.96,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,421.2,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,274.95,58.75,,250.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,219.96,47,,59.784,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,219.96,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,219.96,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,219.96,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,219.96,421.2,
SHOULDER 1 VW RIGHT,3010139,CDM,320,RC,73020,HCPCS,Outpatient,,,134.00,134.00,RT,78.73,58.75,,318.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,78.73,58.75,,318.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.87,48.41,,61.576,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,19.08,fee Schedule,100% of BCBS fee schedule,76.62,100,,9.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,62.98,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,9.36,Fee Schedule,100% of BCBS PPO fee schedule,78.73,58.75,,318.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,62.98,47,,59.784,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,62.98,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,21.31,115,,13.912,Fee Schedule,115% of CMS OPPS Rate,21.31,115,,3.384,Fee Schedule,115% of CMS OPPS Rate,21.31,211.49,
IVP,3010156,CDM,320,RC,74400,HCPCS,Outpatient,,,552.00,552.00,,324.3,58.75,,262.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,324.3,58.75,,262.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,267.22,48.41,,77.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,7.92,fee Schedule,100% of BCBS fee schedule,174.94,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,259.44,47,,75.2,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,324.3,58.75,,262.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,259.44,47,,75.2,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,259.44,47,,75.2,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,129.04,115,,3.384,Fee Schedule,115% of CMS OPPS Rate,129.04,115,,8.648,Fee Schedule,115% of CMS OPPS Rate,75.19,467.02,
FEMUR 2 VIEWS RT,3010161,CDM,320,RC,73552,HCPCS,Outpatient,,,199.65,199.65,RT,117.29,58.75,,276.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,117.29,58.75,,276.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.65,48.41,,67.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,93.84,47,,65.8,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,117.29,58.75,,276.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,93.84,47,,65.8,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,93.84,47,,65.8,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,34.9,115,,8.648,Fee Schedule,115% of CMS OPPS Rate,34.9,115,,60.16,Fee Schedule,115% of CMS OPPS Rate,34.9,211.49,
OPTIC FORAMINA,3010164,CDM,320,RC,70190,HCPCS,Outpatient,,,191.00,191.00,,112.21,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,112.21,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,92.46,48.41,,135.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,40.392,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,89.77,47,,131.6,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,112.21,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,89.77,47,,131.6,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,89.77,47,,131.6,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,36.66,115,,60.16,Fee Schedule,115% of CMS OPPS Rate,36.66,115,,8.648,Fee Schedule,115% of CMS OPPS Rate,36.66,211.49,
SPINE ANY 1 VIEW,3010166,CDM,320,RC,72020,HCPCS,Outpatient,,,183.92,183.92,,108.05,58.75,,358.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,108.05,58.75,,358.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.04,48.41,,73.272,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,4.32,fee Schedule,100% of BCBS fee schedule,76.62,100,,196.56,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,86.44,47,,71.136,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,196.56,Fee Schedule,100% of BCBS PPO fee schedule,108.05,58.75,,358.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,86.44,47,,71.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,86.44,47,,71.136,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,23.93,115,,8.648,Fee Schedule,115% of CMS OPPS Rate,23.93,115,,31.96,Fee Schedule,115% of CMS OPPS Rate,23.93,211.49,
CYSTOGRAPHY,3010168,CDM,320,RC,74430,HCPCS,Outpatient,,,617.00,617.00,,362.49,58.75,,250.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,362.49,58.75,,250.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,298.69,48.41,,70.288,Percent of Total Billed Charges,48.41% of Total Billed Charges,366.59,100,,36.72,fee Schedule,100% of BCBS fee schedule,366.59,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,289.99,47,,68.248,Percent of Total Billed Charges,47% of Total Billed Charges,366.59,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,362.49,58.75,,250.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,289.99,47,,68.248,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,289.99,47,,68.248,Percent of Total Billed Charges,47% of Total Billed Charges,962.78,160,,,Fee Schedule,160% of UHC fee schedule,40.95,115,,31.96,Fee Schedule,115% of CMS OPPS Rate,40.95,115,,6.392,Fee Schedule,115% of CMS OPPS Rate,40.95,962.78,
ZYGOMETIC ARCHES,3010170,CDM,320,RC,70150,HCPCS,Outpatient,,,191.00,191.00,,112.21,58.75,,252.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,112.21,58.75,,252.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,92.46,48.41,,149.104,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,19.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,89.77,47,,144.76,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,19.08,Fee Schedule,100% of BCBS PPO fee schedule,112.21,58.75,,252.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,89.77,47,,144.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,89.77,47,,144.76,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,45.89,115,,6.392,Fee Schedule,115% of CMS OPPS Rate,45.89,115,,4.888,Fee Schedule,115% of CMS OPPS Rate,45.89,284.64,
HIP 1 VIEW,3010175,CDM,320,RC,73501,HCPCS,Outpatient,,,114.00,114.00,,66.98,58.75,,107.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.98,58.75,,107.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,55.19,48.41,,49.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,5.04,fee Schedule,100% of BCBS fee schedule,76.62,100,,7.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,53.58,47,,47.752,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,7.92,Fee Schedule,100% of BCBS PPO fee schedule,66.98,58.75,,107.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,53.58,47,,47.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,53.58,47,,47.752,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,32.67,115,,4.888,Fee Schedule,115% of CMS OPPS Rate,32.67,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,32.67,211.49,
ACUTE ABD SERIES,3010255,CDM,320,RC,74022,HCPCS,Outpatient,,,300.30,300.30,,176.43,58.75,,118.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,176.43,58.75,,118.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.38,48.41,,63.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,5.04,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,141.14,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,176.43,58.75,,118.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,141.14,47,,62.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,141.14,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,49.27,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,49.27,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,49.27,284.64,
SELLA TURCICA,3010272,CDM,320,RC,70240,HCPCS,Outpatient,,,159.00,159.00,,93.41,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,93.41,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.97,48.41,,79.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,36,fee Schedule,100% of BCBS fee schedule,76.62,100,,40.392,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,74.73,47,,76.896,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,40.392,Fee Schedule,100% of BCBS PPO fee schedule,93.41,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,74.73,47,,76.896,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,74.73,47,,76.896,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,32.09,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,32.09,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,32.09,211.49,
VENOGRAM EXT.UNILAT,3010328,CDM,320,RC,75820,HCPCS,Outpatient,,,520.00,520.00,,305.5,58.75,,268.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,305.5,58.75,,268.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,251.73,48.41,,70.288,Percent of Total Billed Charges,48.41% of Total Billed Charges,605.31,100,,3.6,fee Schedule,100% of BCBS fee schedule,605.31,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,244.4,47,,68.248,Percent of Total Billed Charges,47% of Total Billed Charges,605.31,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,305.5,58.75,,268.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,244.4,47,,68.248,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,244.4,47,,68.248,Percent of Total Billed Charges,47% of Total Billed Charges,3676.58,160,,,Fee Schedule,160% of UHC fee schedule,106.18,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,106.18,115,,102.648,Fee Schedule,115% of CMS OPPS Rate,106.18,3676.58,
U/S ABD SINGLE ORGAN,3020000,CDM,402,RC,76705,HCPCS,Outpatient,,,350.00,350.00,,205.63,58.75,,126.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,205.63,58.75,,126.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,169.44,48.41,,49.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,36.72,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,164.5,47,,47.752,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,36.72,Fee Schedule,100% of BCBS PPO fee schedule,205.63,58.75,,126.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,164.5,47,,47.752,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,164.5,47,,47.752,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,85.73,115,,102.648,Fee Schedule,115% of CMS OPPS Rate,85.73,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,45.83,284.64,
U/S ABD RENAL-AORTA LIMITED,3020001,CDM,402,RC,76775,HCPCS,Outpatient,,,318.00,318.00,,186.83,58.75,,119.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,186.83,58.75,,119.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,153.94,48.41,,89.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,149.46,47,,86.48,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,186.83,58.75,,119.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,149.46,47,,86.48,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,149.46,47,,86.48,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,60.73,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,60.73,115,,9.968,Fee Schedule,115% of CMS OPPS Rate,60.73,284.64,
U/S ABDOMEN SURVEY COMPLETE,3020002,CDM,402,RC,76700,HCPCS,Outpatient,,,445.00,445.00,,261.44,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,261.44,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,215.42,48.41,,58.768,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,209.15,47,,57.056,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,261.44,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,209.15,47,,57.056,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,209.15,47,,57.056,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,114.14,115,,9.968,Fee Schedule,115% of CMS OPPS Rate,114.14,115,,4.136,Fee Schedule,115% of CMS OPPS Rate,45.83,284.64,
U/S DUP AORTA IVC CO,3020004,CDM,921,RC,93978,HCPCS,Outpatient,,,533.00,533.00,,313.14,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,313.14,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,258.03,48.41,,136.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,223.73,100,,3.6,fee Schedule,100% of BCBS fee schedule,223.73,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,250.51,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,223.73,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,313.14,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,250.51,47,,132.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,250.51,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,174.36,115,,4.136,Fee Schedule,115% of CMS OPPS Rate,174.36,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,174.36,313.14,
U/S DUPLEX AORTA LIM,3020005,CDM,921,RC,93979,HCPCS,Outpatient,,,534.00,534.00,,313.73,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,313.73,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,258.51,48.41,,123.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,5.04,fee Schedule,100% of BCBS fee schedule,107.6,100,,36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,250.98,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,36,Fee Schedule,100% of BCBS PPO fee schedule,313.73,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,250.98,47,,119.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,250.98,47,,119.568,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,113.36,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,113.36,115,,21.096,Fee Schedule,115% of CMS OPPS Rate,107.6,313.73,
DU ART BIL LOW EXTRE,3020006,CDM,921,RC,93925,HCPCS,Outpatient,,,677.00,677.00,,397.74,58.75,,250.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,397.74,58.75,,250.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,327.74,48.41,,75.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,223.73,100,,3.6,fee Schedule,100% of BCBS fee schedule,223.73,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,318.19,47,,73.32,Percent of Total Billed Charges,47% of Total Billed Charges,223.73,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,397.74,58.75,,250.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,318.19,47,,73.32,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,318.19,47,,73.32,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,229.38,115,,21.096,Fee Schedule,115% of CMS OPPS Rate,229.38,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,223.73,397.74,
DUP ART BIL UP EXTRE,3020007,CDM,921,RC,93930,HCPCS,Outpatient,,,559.00,559.00,,328.41,58.75,,227.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,328.41,58.75,,227.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,270.61,48.41,,135.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,223.73,100,,3.6,fee Schedule,100% of BCBS fee schedule,223.73,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,262.73,47,,131.6,Percent of Total Billed Charges,47% of Total Billed Charges,223.73,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,328.41,58.75,,227.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,262.73,47,,131.6,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,262.73,47,,131.6,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,191.51,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,191.51,115,,19.176,Fee Schedule,115% of CMS OPPS Rate,191.51,328.41,
DUP ART UNI LOWEXTR,3020008,CDM,921,RC,93926,HCPCS,Outpatient,,,587.40,587.40,,345.1,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,345.1,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,284.36,48.41,,61.576,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,276.08,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,345.1,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,276.08,47,,59.784,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,276.08,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,137.67,115,,19.176,Fee Schedule,115% of CMS OPPS Rate,137.67,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,107.6,345.1,
DUP ART UNI UPPER EX,3020009,CDM,921,RC,93931,HCPCS,Outpatient,,,318.00,318.00,,186.83,58.75,,176.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,186.83,58.75,,176.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,153.94,48.41,,110.76,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,5.04,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,149.46,47,,107.536,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,186.83,58.75,,176.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,149.46,47,,107.536,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,149.46,47,,107.536,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,118.92,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,118.92,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,107.6,186.83,
U/S DUPLEX CARTOID,3020010,CDM,921,RC,93880,HCPCS,Outpatient,,,762.00,762.00,,447.68,58.75,,110.896,Percent of Total Billed Charges,58.75% of Total Billed Charges,447.68,58.75,,110.896,Percent of Total Billed Charges,58.75% of Total Billed Charges,368.88,48.41,,149.104,Percent of Total Billed Charges,48.41% of Total Billed Charges,223.73,100,,21.6,fee Schedule,100% of BCBS fee schedule,223.73,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,358.14,47,,144.76,Percent of Total Billed Charges,47% of Total Billed Charges,223.73,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,447.68,58.75,,110.896,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,358.14,47,,144.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,358.14,47,,144.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,182.8,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,182.8,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,182.8,447.68,
DUPLEX EXT VEINBIL,3020011,CDM,921,RC,93970,HCPCS,Outpatient,,,533.50,533.50,,313.43,58.75,,126.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,313.43,58.75,,126.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,258.27,48.41,,50.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,223.73,100,,5.544,fee Schedule,100% of BCBS fee schedule,223.73,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,250.75,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,223.73,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,313.43,58.75,,126.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,250.75,47,,48.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,250.75,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,179.53,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,179.53,115,,18.8,Fee Schedule,115% of CMS OPPS Rate,179.53,313.43,
DUP EXT VEIN UNILAT,3020012,CDM,921,RC,93971,HCPCS,Outpatient,,,537.00,537.00,,315.49,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,315.49,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,259.96,48.41,,59.64,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,252.39,47,,57.904,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,315.49,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,252.39,47,,57.904,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,252.39,47,,57.904,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,114.95,115,,18.8,Fee Schedule,115% of CMS OPPS Rate,114.95,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,107.6,315.49,
US BODY SUPERFCL RT,3020015,CDM,402,RC,76882,HCPCS,Outpatient,,,228.70,228.70,RT,134.36,58.75,,140.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,134.36,58.75,,140.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,110.71,48.41,,65.608,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,1.44,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,107.49,47,,63.696,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,134.36,58.75,,140.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,107.49,47,,63.696,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,107.49,47,,63.696,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,64.7,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,64.7,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,64.7,284.64,
US BODY SUPERFCL LT,3020016,CDM,402,RC,76881,HCPCS,Outpatient,,,252.00,252.00,,148.05,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,148.05,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,121.99,48.41,,67.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,118.44,47,,65.8,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,148.05,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.94,100,,,Fee Schedule,100% of ASC Tier Groupings,118.44,47,,65.8,Percent of Total Billed Charges,47% of Total Billed charges,22.94,100,,,Fee Schedule,100% ASC Tier Groupings,118.44,47,,65.8,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,55.23,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,55.23,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,22.94,284.64,
U/S INFANT HIPS,3020017,CDM,402,RC,76885,HCPCS,Outpatient,,,318.00,318.00,,186.83,58.75,,80.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,186.83,58.75,,80.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,153.94,48.41,,67.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,18,fee Schedule,100% of BCBS fee schedule,76.62,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,149.46,47,,65.8,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,186.83,58.75,,80.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,149.46,47,,65.8,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,149.46,47,,65.8,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,132.01,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,132.01,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,76.62,211.49,
U/S OB> 14 WKS,3020018,CDM,402,RC,76805,HCPCS,Outpatient,,,572.00,572.00,,336.05,58.75,,456.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,336.05,58.75,,456.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,276.91,48.41,,38.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,6.48,fee Schedule,100% of BCBS fee schedule,107.6,100,,21.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,268.84,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,21.6,Fee Schedule,100% of BCBS PPO fee schedule,336.05,58.75,,456.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,268.84,47,,37.6,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,268.84,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,132.99,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,132.99,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,45.83,336.05,
U/S OB LIMITED,3020019,CDM,402,RC,76815,HCPCS,Outpatient,,,270.00,270.00,,158.63,58.75,,176.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,158.63,58.75,,176.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,130.71,48.41,,96.824,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,9.36,fee Schedule,100% of BCBS fee schedule,107.6,100,,5.544,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,126.9,47,,94,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,5.544,Fee Schedule,100% of BCBS PPO fee schedule,158.63,58.75,,176.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,126.9,47,,94,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,126.9,47,,94,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,80.29,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,80.29,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,80.29,284.64,
US OB MULTI GEST>14W,3020020,CDM,402,RC,76810,HCPCS,Outpatient,,,254.00,254.00,,149.23,58.75,,217.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,149.23,58.75,,217.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,122.96,48.41,,81.192,Percent of Total Billed Charges,48.41% of Total Billed Charges,39.77,100,,3.6,fee Schedule,100% of BCBS fee schedule,39.77,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,119.38,47,,78.824,Percent of Total Billed Charges,47% of Total Billed Charges,39.77,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,149.23,58.75,,217.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,119.38,47,,78.824,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,119.38,47,,78.824,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,87.57,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,87.57,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,39.77,149.23,
U/S TESTICULAR,3020021,CDM,402,RC,76870,HCPCS,Outpatient,,,318.00,318.00,,186.83,58.75,,488.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,186.83,58.75,,488.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,153.94,48.41,,568.528,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,1.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,149.46,47,,551.968,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,1.44,Fee Schedule,100% of BCBS PPO fee schedule,186.83,58.75,,488.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,149.46,47,,551.968,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,149.46,47,,551.968,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,98.35,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,98.35,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,98.35,284.64,
U/S HEAD/NECK,3020022,CDM,402,RC,76536,HCPCS,Outpatient,,,318.00,318.00,,186.83,58.75,,143.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,186.83,58.75,,143.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,153.94,48.41,,503.848,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,18,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,149.46,47,,489.176,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,186.83,58.75,,143.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,149.46,47,,489.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,149.46,47,,489.176,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,107.2,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,107.2,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,107.2,284.64,
U/S TRANSVAGINAL,3020023,CDM,402,RC,76830,HCPCS,Outpatient,,,318.00,318.00,,186.83,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,186.83,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,153.94,48.41,,688.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,18,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,149.46,47,,668.904,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,18,Fee Schedule,100% of BCBS PPO fee schedule,186.83,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,149.46,47,,668.904,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,149.46,47,,668.904,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,115.87,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,115.87,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,45.83,284.64,
US VASCULAR ABDCOMP,3020024,CDM,402,RC,93975,HCPCS,Outpatient,,,533.00,533.00,,313.14,58.75,,177.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,313.14,58.75,,177.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,258.03,48.41,,486.928,Percent of Total Billed Charges,48.41% of Total Billed Charges,223.73,100,,70.56,fee Schedule,100% of BCBS fee schedule,223.73,100,,6.48,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,250.51,47,,472.744,Percent of Total Billed Charges,47% of Total Billed Charges,223.73,100,,6.48,Fee Schedule,100% of BCBS PPO fee schedule,313.14,58.75,,177.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,250.51,47,,472.744,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,250.51,47,,472.744,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,254.36,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,254.36,115,,11.28,Fee Schedule,115% of CMS OPPS Rate,223.73,313.14,
US VASCULAR LIMI,3020025,CDM,402,RC,93976,HCPCS,Outpatient,,,485.00,485.00,,284.94,58.75,,263.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,284.94,58.75,,263.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,234.79,48.41,,565.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,15.696,fee Schedule,100% of BCBS fee schedule,107.6,100,,9.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,227.95,47,,549.336,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,9.36,Fee Schedule,100% of BCBS PPO fee schedule,284.94,58.75,,263.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,227.95,47,,549.336,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,227.95,47,,549.336,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,154.58,115,,11.28,Fee Schedule,115% of CMS OPPS Rate,154.58,115,,2.896,Fee Schedule,115% of CMS OPPS Rate,107.6,284.94,
U/S TRANSVAG (OB),3020026,CDM,402,RC,76817,HCPCS,Outpatient,,,318.00,318.00,,186.83,58.75,,62.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,186.83,58.75,,62.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,153.94,48.41,,605.008,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,483.84,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,149.46,47,,587.384,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,186.83,58.75,,62.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,149.46,47,,587.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,149.46,47,,587.384,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,91.37,115,,2.896,Fee Schedule,115% of CMS OPPS Rate,91.37,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,91.37,284.64,
U/S RENAL COMPLETE,3020027,CDM,402,RC,76770,HCPCS,Outpatient,,,375.00,375.00,,220.31,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,220.31,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,181.54,48.41,,516.632,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,20.88,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,176.25,47,,501.584,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,220.31,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,176.25,47,,501.584,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,176.25,47,,501.584,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,106.41,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,106.41,115,,0.752,Fee Schedule,115% of CMS OPPS Rate,45.83,284.64,
U/S BREAST/CHEST LIMITED,3020028,CDM,402,RC,76642,HCPCS,Outpatient,,,235.95,235.95,,138.62,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,138.62,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,114.22,48.41,,803.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,18,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,110.9,47,,780.464,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,18,Fee Schedule,100% of BCBS PPO fee schedule,138.62,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,110.9,47,,780.464,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,110.9,47,,780.464,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,84.16,115,,0.752,Fee Schedule,115% of CMS OPPS Rate,84.16,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,76.62,211.49,
LIMITED PELVIS US,3020029,CDM,402,RC,76857,HCPCS,Outpatient,,,270.00,270.00,,158.63,58.75,,86.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,158.63,58.75,,86.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,130.71,48.41,,639.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,126.9,47,,621.152,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,158.63,58.75,,86.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.66,100,,,Fee Schedule,100% of ASC Tier Groupings,126.9,47,,621.152,Percent of Total Billed Charges,47% of Total Billed charges,19.66,100,,,Fee Schedule,100% ASC Tier Groupings,126.9,47,,621.152,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,50.2,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,50.2,115,,9.4,Fee Schedule,115% of CMS OPPS Rate,19.66,284.64,
US ABDOMINAL AORTA SCREENING,3020030,CDM,402,RC,76706,HCPCS,Outpatient,,,318.00,318.00,,186.83,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,186.83,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,153.94,48.41,,622.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.96,fee Schedule,100% of BCBS fee schedule,107.6,100,,70.56,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,149.46,47,,604.232,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,70.56,Fee Schedule,100% of BCBS PPO fee schedule,186.83,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,149.46,47,,604.232,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,149.46,47,,604.232,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,104.72,115,,9.4,Fee Schedule,115% of CMS OPPS Rate,104.72,115,,3.384,Fee Schedule,115% of CMS OPPS Rate,104.72,284.64,
US BLADDER,3020031,CDM,402,RC,76857,HCPCS,Outpatient,,,298.00,298.00,,175.08,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,175.08,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,144.26,48.41,,472.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,5.04,fee Schedule,100% of BCBS fee schedule,107.6,100,,15.696,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,140.06,47,,458.72,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,15.696,Fee Schedule,100% of BCBS PPO fee schedule,175.08,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.66,100,,,Fee Schedule,100% of ASC Tier Groupings,140.06,47,,458.72,Percent of Total Billed Charges,47% of Total Billed charges,19.66,100,,,Fee Schedule,100% ASC Tier Groupings,140.06,47,,458.72,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,50.2,115,,3.384,Fee Schedule,115% of CMS OPPS Rate,50.2,115,,4.888,Fee Schedule,115% of CMS OPPS Rate,19.66,284.64,
US RENAL LIMITED,3020032,CDM,402,RC,76775,HCPCS,Outpatient,,,318.00,318.00,,186.83,58.75,,78.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,186.83,58.75,,78.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,153.94,48.41,,714.632,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,12.24,fee Schedule,100% of BCBS fee schedule,107.6,100,,483.84,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,149.46,47,,693.816,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,483.84,Fee Schedule,100% of BCBS PPO fee schedule,186.83,58.75,,78.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,149.46,47,,693.816,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,149.46,47,,693.816,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,60.73,115,,4.888,Fee Schedule,115% of CMS OPPS Rate,60.73,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,60.73,284.64,
KNEE 3 VIEW RIGHT,3020085,CDM,320,RC,73562,HCPCS,Outpatient,,,172.00,172.00,RT,101.05,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,101.05,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,83.27,48.41,,454.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,36.72,fee Schedule,100% of BCBS fee schedule,76.62,100,,20.88,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,80.84,47,,441.312,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,20.88,Fee Schedule,100% of BCBS PPO fee schedule,101.05,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,80.84,47,,441.312,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,80.84,47,,441.312,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,39.71,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,39.71,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,39.71,211.49,
ECHOCARDIOGRAM COMPL,3020088,CDM,483,RC,93306,HCPCS,Outpatient,,,971.00,971.00,,570.46,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,570.46,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,470.06,48.41,,720.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,462.34,100,,5.04,fee Schedule,100% of BCBS fee schedule,462.34,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,456.37,47,,699.736,Percent of Total Billed Charges,47% of Total Billed Charges,462.34,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,570.46,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,456.37,47,,699.736,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,456.37,47,,699.736,Percent of Total Billed Charges,47% of Total Billed Charges,210,100,,,Case Rate,Pays based on per visit rate,192.57,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,192.57,115,,9.4,Fee Schedule,115% of CMS OPPS Rate,192.57,570.46,
ECHO 2-D,3020089,CDM,480,RC,93308,HCPCS,Outpatient,,,375.10,375.10,26,220.37,58.75,,94,Percent of Total Billed Charges,58.75% of Total Billed Charges,220.37,58.75,,94,Percent of Total Billed Charges,58.75% of Total Billed Charges,181.59,48.41,,541.416,Percent of Total Billed Charges,48.41% of Total Billed Charges,223.73,100,,3.6,fee Schedule,100% of BCBS fee schedule,223.73,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,176.3,47,,525.648,Percent of Total Billed Charges,47% of Total Billed Charges,223.73,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,220.37,58.75,,94,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,176.3,47,,525.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,176.3,47,,525.648,Percent of Total Billed Charges,47% of Total Billed Charges,420,100,,,Case Rate,Pays based on per visit rate,95.66,115,,9.4,Fee Schedule,115% of CMS OPPS Rate,95.66,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,95.66,420,
PELVIC US,3040027,CDM,402,RC,76856,HCPCS,Outpatient,,,462.00,462.00,,271.43,58.75,,82.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,271.43,58.75,,82.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,223.65,48.41,,565.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,10.8,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,217.14,47,,549.336,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,271.43,58.75,,82.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,217.14,47,,549.336,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,217.14,47,,549.336,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,103.41,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,103.41,115,,36.848,Fee Schedule,115% of CMS OPPS Rate,45.83,284.64,
FACIAL CT W/O CONTR,3040056,CDM,351,RC,70486,HCPCS,Outpatient,,,1040.00,1040.00,,611,58.75,,164.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,611,58.75,,164.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,503.46,48.41,,516.632,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,70.56,fee Schedule,100% of BCBS fee schedule,107.6,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,488.8,47,,501.584,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,611,58.75,,164.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,488.8,47,,501.584,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,488.8,47,,501.584,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,128.55,115,,36.848,Fee Schedule,115% of CMS OPPS Rate,128.55,115,,8.2,Fee Schedule,115% of CMS OPPS Rate,45.83,611,
POST OP T TUBE,3040058,CDM,320,RC,47531,HCPCS,Outpatient,,,305.00,305.00,,179.19,58.75,,88.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,179.19,58.75,,88.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,147.65,48.41,,503.848,Percent of Total Billed Charges,48.41% of Total Billed Charges,3398.08,100,,4.32,fee Schedule,100% of ASC Tier Groupings ,3398.08,100,,12.24,Fee Schedule,100% of ASC Tier Groupings,143.35,47,,489.176,Percent of Total Billed Charges,47% of Total Billed Charges,3398.08,100,,12.24,Fee Schedule,100% of ASC Tier Groupings,179.19,58.75,,88.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,143.35,47,,489.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,143.35,47,,489.176,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,71.66,115,,8.2,Fee Schedule,115% of CMS OPPS Rate,71.66,115,,252.672,Fee Schedule,115% of CMS OPPS Rate,71.66,3398.08,
OR CHOLONGIOGRAM,3040059,CDM,320,RC,74300,HCPCS,Outpatient,,,318.00,318.00,,186.83,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,186.83,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,153.94,48.41,,757.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,286.2,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,286.2,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,149.46,47,,735.792,Percent of Total Billed Charges,47% of Total Billed Charges,286.2,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,186.83,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,149.46,47,,735.792,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,149.46,47,,735.792,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,149.46,286.2,
FISTULAGRAM,3040061,CDM,320,RC,76080,HCPCS,Outpatient,,,377.00,377.00,,221.49,58.75,,180.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,221.49,58.75,,180.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,182.51,48.41,,595.64,Percent of Total Billed Charges,48.41% of Total Billed Charges,462.34,100,,3.96,fee Schedule,100% of BCBS fee schedule,462.34,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,177.19,47,,578.288,Percent of Total Billed Charges,47% of Total Billed Charges,462.34,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,221.49,58.75,,180.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,177.19,47,,578.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,177.19,47,,578.288,Percent of Total Billed Charges,47% of Total Billed Charges,1263.31,160,,,Fee Schedule,160% of UHC fee schedule,59.75,115,,10.904,Fee Schedule,115% of CMS OPPS Rate,59.75,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,59.75,1263.31,
G TUBE CHANGE S&I,3040062,CDM,320,RC,75984,HCPCS,Outpatient,,,561.00,561.00,,329.59,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,329.59,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,271.58,48.41,,664.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,60.22,100,,5.04,fee Schedule,100% of BCBS fee schedule,60.22,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,263.67,47,,644.84,Percent of Total Billed Charges,47% of Total Billed Charges,60.22,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,329.59,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,263.67,47,,644.84,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,263.67,47,,644.84,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,94.08,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,94.08,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,60.22,329.59,
SHOULDER 1 VIEWLEFT,3040068,CDM,320,RC,73020,HCPCS,Outpatient,,,133.10,133.10,LT,78.2,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,78.2,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.43,48.41,,565.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,6.48,fee Schedule,100% of BCBS fee schedule,76.62,100,,10.8,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,62.56,47,,549.336,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,10.8,Fee Schedule,100% of BCBS PPO fee schedule,78.2,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,62.56,47,,549.336,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,62.56,47,,549.336,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,21.31,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,21.31,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,21.31,211.49,
SHOULDER MIN 2 V LEF,3040070,CDM,320,RC,73030,HCPCS,Outpatient,,,181.50,181.50,LT,106.63,58.75,,96.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,106.63,58.75,,96.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,87.86,48.41,,595.64,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,74.88,fee Schedule,100% of BCBS fee schedule,76.62,100,,70.56,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,85.31,47,,578.288,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,70.56,Fee Schedule,100% of BCBS PPO fee schedule,106.63,58.75,,96.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,85.31,47,,578.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,85.31,47,,578.288,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,33.95,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,33.95,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,33.95,211.49,
HUMEROUS MIN 2 V LT,3040072,CDM,320,RC,73060,HCPCS,Outpatient,,,181.50,181.50,LT,106.63,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,106.63,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,87.86,48.41,,639.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,5.04,fee Schedule,100% of BCBS fee schedule,76.62,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,85.31,47,,621.152,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,106.63,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,85.31,47,,621.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,85.31,47,,621.152,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,31.28,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,31.28,115,,6.392,Fee Schedule,115% of CMS OPPS Rate,31.28,211.49,
ELBOW 2 VIEWS LEFT,3040074,CDM,320,RC,73070,HCPCS,Outpatient,,,184.25,184.25,LT,108.25,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,108.25,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.2,48.41,,696.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,18.216,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,86.6,47,,676.424,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,108.25,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,86.6,47,,676.424,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,86.6,47,,676.424,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,28.73,115,,6.392,Fee Schedule,115% of CMS OPPS Rate,28.73,115,,19.176,Fee Schedule,115% of CMS OPPS Rate,28.73,211.49,
ELBOW MIN 3 VIEW LT,3040076,CDM,320,RC,73080,HCPCS,Outpatient,,,191.00,191.00,LT,112.21,58.75,,108.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,112.21,58.75,,108.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,92.46,48.41,,565.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.96,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,89.77,47,,549.336,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,112.21,58.75,,108.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,89.77,47,,549.336,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,89.77,47,,549.336,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,31.98,115,,19.176,Fee Schedule,115% of CMS OPPS Rate,31.98,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,31.98,211.49,
RAD&ULNA 2 VIEWLT,3040078,CDM,320,RC,73090,HCPCS,Outpatient,,,165.00,165.00,LT,96.94,58.75,,71.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.94,58.75,,71.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.88,48.41,,488.28,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,77.55,47,,474.064,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,96.94,58.75,,71.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.55,47,,474.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,77.55,47,,474.064,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,28.73,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,28.73,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,28.73,211.49,
WRIST 2 VIEW LEFT,3040080,CDM,320,RC,73100,HCPCS,Outpatient,,,167.00,167.00,LT,98.11,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,98.11,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,80.84,48.41,,590.6,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,6.48,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,78.49,47,,573.4,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,6.48,Fee Schedule,100% of BCBS PPO fee schedule,98.11,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,78.49,47,,573.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,78.49,47,,573.4,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,32.88,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,32.88,115,,5.64,Fee Schedule,115% of CMS OPPS Rate,32.88,211.49,
WRIST 3 VIEWS LEFT,3040082,CDM,320,RC,73110,HCPCS,Outpatient,,,159.00,159.00,LT,93.41,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,93.41,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.97,48.41,,516.632,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.96,fee Schedule,100% of BCBS fee schedule,76.62,100,,74.88,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,74.73,47,,501.584,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,74.88,Fee Schedule,100% of BCBS PPO fee schedule,93.41,58.75,,149.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,74.73,47,,501.584,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,74.73,47,,501.584,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,40.3,115,,5.64,Fee Schedule,115% of CMS OPPS Rate,40.3,115,,36.848,Fee Schedule,115% of CMS OPPS Rate,40.3,211.49,
HAND 3 VIEWS LEFT,3040084,CDM,320,RC,73130,HCPCS,Outpatient,,,159.00,159.00,LT,93.41,58.75,,91.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,93.41,58.75,,91.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.97,48.41,,443.92,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,5.04,fee Schedule,100% of BCBS fee schedule,76.62,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,74.73,47,,430.992,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,93.41,58.75,,91.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,74.73,47,,430.992,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,74.73,47,,430.992,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,36.46,115,,36.848,Fee Schedule,115% of CMS OPPS Rate,36.46,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,36.46,211.49,
FEMUR 2 VIEWS LEFT,3040086,CDM,320,RC,73552,HCPCS,Outpatient,,,200.00,200.00,LT,117.5,58.75,,164.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,117.5,58.75,,164.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.82,48.41,,74.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,18.216,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,94,47,,72.568,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,18.216,Fee Schedule,100% of BCBS PPO fee schedule,117.5,58.75,,164.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,94,47,,72.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,94,47,,72.568,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,34.9,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,34.9,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,34.9,211.49,
KNEE 1-2 VIEWS LEFT,3040088,CDM,320,RC,73560,HCPCS,Outpatient,,,175.00,175.00,LT,102.81,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,102.81,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.72,48.41,,65.448,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,4.32,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,82.25,47,,63.544,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,102.81,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,82.25,47,,63.544,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,82.25,47,,63.544,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,33.2,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,33.2,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,33.2,211.49,
KNEEW 1-2VW BILATER,3040089,CDM,320,RC,73560,HCPCS,Outpatient,,,350.00,350.00,50,205.63,58.75,,134.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,205.63,58.75,,134.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,169.44,48.41,,78.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,12.24,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,164.5,47,,76.328,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,205.63,58.75,,134.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,164.5,47,,76.328,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,164.5,47,,76.328,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,33.2,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,33.2,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,33.2,211.49,
KNEE 3 VIEW LEFT,3040090,CDM,320,RC,73562,HCPCS,Outpatient,,,189.20,189.20,LT,111.16,58.75,,180.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,111.16,58.75,,180.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,91.59,48.41,,63.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,88.92,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,111.16,58.75,,180.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,88.92,47,,62.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,88.92,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,39.71,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,39.71,115,,3.384,Fee Schedule,115% of CMS OPPS Rate,39.71,211.49,
TIB/FIB 2 VW LEFT,3040092,CDM,320,RC,73590,HCPCS,Outpatient,,,181.50,181.50,LT,106.63,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,106.63,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,87.86,48.41,,73.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.96,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,85.31,47,,71.816,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,106.63,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,85.31,47,,71.816,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,85.31,47,,71.816,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,30.97,115,,3.384,Fee Schedule,115% of CMS OPPS Rate,30.97,115,,39.104,Fee Schedule,115% of CMS OPPS Rate,30.97,211.49,
TIB/FIB 2 VW BILATER,3040093,CDM,320,RC,73590,HCPCS,Outpatient,,,385.00,385.00,50,226.19,58.75,,72.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,226.19,58.75,,72.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,186.38,48.41,,65.064,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,6.12,fee Schedule,100% of BCBS fee schedule,76.62,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,180.95,47,,63.168,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,226.19,58.75,,72.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,180.95,47,,63.168,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,180.95,47,,63.168,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,30.97,115,,39.104,Fee Schedule,115% of CMS OPPS Rate,30.97,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,30.97,226.19,
ANKLE 2 VIEWS LEFT,3040094,CDM,320,RC,73600,HCPCS,Outpatient,,,127.00,127.00,LT,74.61,58.75,,79.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.61,58.75,,79.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.48,48.41,,74.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,4.32,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,59.69,47,,72.192,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,74.61,58.75,,79.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,59.69,47,,72.192,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,59.69,47,,72.192,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,31.28,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,31.28,115,,9.512,Fee Schedule,115% of CMS OPPS Rate,31.28,211.49,
ANKLE 3 VIEWS LEFT,3040096,CDM,320,RC,73610,HCPCS,Outpatient,,,165.00,165.00,LT,96.94,58.75,,82.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.94,58.75,,82.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.88,48.41,,65.064,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,7.92,fee Schedule,100% of BCBS fee schedule,76.62,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,77.55,47,,63.168,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,96.94,58.75,,82.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.55,47,,63.168,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,77.55,47,,63.168,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,35.5,115,,9.512,Fee Schedule,115% of CMS OPPS Rate,35.5,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,35.5,211.49,
FOOT 2 VIEWS LEFT,3040098,CDM,320,RC,73620,HCPCS,Outpatient,,,204.50,204.50,LT,120.14,58.75,,82.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,120.14,58.75,,82.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,99,48.41,,58.864,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,12.24,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,96.12,47,,57.152,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,12.24,Fee Schedule,100% of BCBS PPO fee schedule,120.14,58.75,,82.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,96.12,47,,57.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,96.12,47,,57.152,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,27.76,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,27.76,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,27.76,211.49,
FOOT RAD 3 VIEWLEFT,3040100,CDM,320,RC,73630,HCPCS,Outpatient,,,181.50,181.50,LT,106.63,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,106.63,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,87.86,48.41,,64.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,85.31,47,,62.864,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,106.63,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,85.31,47,,62.864,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,85.31,47,,62.864,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,33.26,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,33.26,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,33.26,211.49,
CALCANEUS 2 VW LEFT,3040102,CDM,320,RC,73650,HCPCS,Outpatient,,,127.00,127.00,LT,74.61,58.75,,117.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.61,58.75,,117.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.48,48.41,,54.104,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,5.04,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,59.69,47,,52.528,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,74.61,58.75,,117.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,59.69,47,,52.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,59.69,47,,52.528,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,27.76,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,27.76,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,27.76,211.49,
ULTRAVIST 100 ML,3040107,CDM,255,RC,,,Outpatient,,,230.00,230.00,,135.13,58.75,,98.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,135.13,58.75,,98.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,111.34,48.41,,70.288,Percent of Total Billed Charges,48.41% of Total Billed Charges,207,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,207,90,,6.12,Percent of Total Billed Charges,90% of Total Billed Charges,108.1,47,,68.248,Percent of Total Billed Charges,47% of Total Billed Charges,207,90,,6.12,Percent of Total Billed Charges,90% of Total Billed Charges,135.13,58.75,,98.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,108.1,47,,68.248,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,108.1,47,,68.248,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,108.1,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,108.1,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,108.1,207,
EKG W 12 LEADS TRAC,3040110,CDM,730,RC,93005,HCPCS,Outpatient,,,151.75,151.75,,89.15,58.75,,689.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.15,58.75,,689.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.46,48.41,,443.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,52.81,100,,3.6,fee Schedule,100% of BCBS fee schedule,52.81,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,71.32,47,,430.968,Percent of Total Billed Charges,47% of Total Billed Charges,52.81,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,89.15,58.75,,689.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,71.32,47,,430.968,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,71.32,47,,430.968,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,5.95,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,5.95,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,5.95,90,
EKG 12 LEAD INTER RP,3040111,CDM,985,RC,93010,HCPCS,Outpatient,,,125.40,125.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
HOLTER MONITOR HOOKP,3040112,CDM,731,RC,93225,HCPCS,Outpatient,,,352.00,352.00,,206.8,58.75,,836.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,206.8,58.75,,836.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,170.4,48.41,,590.6,Percent of Total Billed Charges,48.41% of Total Billed Charges,104.67,100,,5.04,fee Schedule,100% of BCBS fee schedule,104.67,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,165.44,47,,573.4,Percent of Total Billed Charges,47% of Total Billed Charges,104.67,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,206.8,58.75,,836.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,165.44,47,,573.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,165.44,47,,573.4,Percent of Total Billed Charges,47% of Total Billed Charges,263,100,,,Case Rate,Pays based on per visit rate,17.15,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,17.15,115,,6.392,Fee Schedule,115% of CMS OPPS Rate,17.15,263,
OB U/S < 14 WKS,3040114,CDM,402,RC,76801,HCPCS,Outpatient,,,318.00,318.00,,186.83,58.75,,590.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,186.83,58.75,,590.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,153.94,48.41,,467.448,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,5.04,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,149.46,47,,453.832,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,186.83,58.75,,590.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,149.46,47,,453.832,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,149.46,47,,453.832,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,116.16,115,,6.392,Fee Schedule,115% of CMS OPPS Rate,116.16,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,45.83,284.64,
OB U/S MULTIGES<14W,3040115,CDM,402,RC,76802,HCPCS,Outpatient,,,195.00,195.00,,114.56,58.75,,686.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,114.56,58.75,,686.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,94.4,48.41,,649.664,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.45,100,,8.64,fee Schedule,100% of BCBS fee schedule,20.45,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,91.65,47,,630.744,Percent of Total Billed Charges,47% of Total Billed Charges,20.45,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,114.56,58.75,,686.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,91.65,47,,630.744,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,91.65,47,,630.744,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,61.2,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,61.2,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,20.45,114.56,
OB U/S TRANSVAG,3040116,CDM,402,RC,76817,HCPCS,Outpatient,,,350.00,350.00,,205.63,58.75,,734.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,205.63,58.75,,734.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,169.44,48.41,,639.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,49.68,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,164.5,47,,621.152,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,205.63,58.75,,734.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,164.5,47,,621.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,164.5,47,,621.152,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,91.37,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,91.37,115,,3.2,Fee Schedule,115% of CMS OPPS Rate,91.37,284.64,
INFANT BONE SURVEY,3040118,CDM,320,RC,77076,HCPCS,Outpatient,,,159.00,159.00,,93.41,58.75,,626.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,93.41,58.75,,626.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.97,48.41,,553.888,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,9.36,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,74.73,47,,537.752,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,93.41,58.75,,626.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,74.73,47,,537.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,74.73,47,,537.752,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,105.57,115,,3.2,Fee Schedule,115% of CMS OPPS Rate,105.57,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,74.73,284.64,
LIMITED BONE SURVEY,3040119,CDM,320,RC,77074,HCPCS,Outpatient,,,286.00,286.00,,168.03,58.75,,975.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,168.03,58.75,,975.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,138.45,48.41,,516.632,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,18,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,134.42,47,,501.584,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,18,Fee Schedule,100% of BCBS PPO fee schedule,168.03,58.75,,975.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,134.42,47,,501.584,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,134.42,47,,501.584,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,64.61,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,64.61,115,,4.136,Fee Schedule,115% of CMS OPPS Rate,64.61,284.64,
HOLTER MONITOR COMPL,3040120,CDM,731,RC,93224,HCPCS,Outpatient,,,385.00,385.00,,226.19,58.75,,776.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,226.19,58.75,,776.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,186.38,48.41,,639.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,346.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,346.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,180.95,47,,621.152,Percent of Total Billed Charges,47% of Total Billed Charges,346.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,226.19,58.75,,776.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,180.95,47,,621.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,180.95,47,,621.152,Percent of Total Billed Charges,47% of Total Billed Charges,263,100,,,Case Rate,Pays based on per visit rate,69.15,115,,4.136,Fee Schedule,115% of CMS OPPS Rate,69.15,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,69.15,346.5,
HOLTER SCANNINGONLY,3040121,CDM,731,RC,93226,HCPCS,Outpatient,,,130.00,130.00,,76.38,58.75,,755.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.38,58.75,,755.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.93,48.41,,503.848,Percent of Total Billed Charges,48.41% of Total Billed Charges,104.67,100,,10.08,fee Schedule,100% of BCBS fee schedule,104.67,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,61.1,47,,489.176,Percent of Total Billed Charges,47% of Total Billed Charges,104.67,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,76.38,58.75,,755.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,61.1,47,,489.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,61.1,47,,489.176,Percent of Total Billed Charges,47% of Total Billed Charges,263,100,,,Case Rate,Pays based on per visit rate,32.82,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,32.82,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,32.82,263,
HAND 2 VIEWS LEFT,3040122,CDM,320,RC,73120,HCPCS,Outpatient,,,154.00,154.00,LT,90.48,58.75,,573.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,90.48,58.75,,573.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.55,48.41,,516.632,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,4.32,fee Schedule,100% of BCBS fee schedule,107.6,100,,8.64,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,72.38,47,,501.584,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,8.64,Fee Schedule,100% of BCBS PPO fee schedule,90.48,58.75,,573.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,72.38,47,,501.584,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,72.38,47,,501.584,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,30.65,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.65,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,30.65,284.64,
HAND 2 VIEWS RIGHT,3040123,CDM,320,RC,73120,HCPCS,Outpatient,,,169.40,169.40,RT,99.52,58.75,,867.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,99.52,58.75,,867.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,82.01,48.41,,688.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,5.76,fee Schedule,100% of BCBS fee schedule,107.6,100,,49.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,79.62,47,,668.904,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,49.68,Fee Schedule,100% of BCBS PPO fee schedule,99.52,58.75,,867.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,79.62,47,,668.904,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,79.62,47,,668.904,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,30.65,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,30.65,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.65,284.64,
KNEE 4 VIEWS LEFT,3040125,CDM,320,RC,73564,HCPCS,Outpatient,,,175.00,175.00,LT,102.81,58.75,,551.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,102.81,58.75,,551.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.72,48.41,,231.208,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,9.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,82.25,47,,224.472,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,9.36,Fee Schedule,100% of BCBS PPO fee schedule,102.81,58.75,,551.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,82.25,47,,224.472,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,82.25,47,,224.472,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,46.31,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,46.31,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,46.31,284.64,
KNEE 4 VIEWS RIGHT,3040126,CDM,320,RC,73564,HCPCS,Outpatient,,,175.00,175.00,RT,102.81,58.75,,874.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,102.81,58.75,,874.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.72,48.41,,240.504,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,12.24,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,82.25,47,,233.496,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,102.81,58.75,,874.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,82.25,47,,233.496,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,82.25,47,,233.496,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,46.31,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,46.31,115,,9.4,Fee Schedule,115% of CMS OPPS Rate,46.31,284.64,
AP (WT BEARING) LOWER EXT.,3040127,CDM,320,RC,76499,HCPCS,Outpatient,,,100.00,100.00,,58.75,58.75,,657.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.75,58.75,,657.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.41,48.41,,848.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,7.92,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,47,47,,824.008,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,58.75,58.75,,657.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47,47,,824.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47,47,,824.008,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,47,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,47,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,47,211.49,
XRAY PELVIS MINIMUM 3 VIEWS,3040129,CDM,320,RC,72190,HCPCS,Outpatient,,,250.00,250.00,,146.88,58.75,,686.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,146.88,58.75,,686.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,121.03,48.41,,1134.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,10.08,fee Schedule,100% of BCBS fee schedule,107.6,100,,10.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,117.5,47,,1101,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,10.08,Fee Schedule,100% of BCBS PPO fee schedule,146.88,58.75,,686.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,117.5,47,,1101,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,117.5,47,,1101,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,41.35,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,41.35,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,41.35,284.64,
THORASIC SPINE 4 VIEWS,304128,CDM,320,RC,72074,HCPCS,Outpatient,,,209.64,209.64,,123.16,58.75,,626.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,123.16,58.75,,626.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,101.49,48.41,,1095.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,10.08,fee Schedule,100% of BCBS fee schedule,107.6,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,98.53,47,,1063.984,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,123.16,58.75,,626.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,98.53,47,,1063.984,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,98.53,47,,1063.984,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,43.91,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,43.91,115,,4.512,Fee Schedule,115% of CMS OPPS Rate,43.91,284.64,
CT UPPER EX W CONTRT,3050000,CDM,352,RC,73201,HCPCS,Outpatient,,,1468.00,1468.00,RT,862.45,58.75,,611.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,862.45,58.75,,611.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,710.66,48.41,,848.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,366.59,100,,7.92,fee Schedule,100% of BCBS fee schedule,366.59,100,,5.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,689.96,47,,824.008,Percent of Total Billed Charges,47% of Total Billed Charges,366.59,100,,5.76,Fee Schedule,100% of BCBS PPO fee schedule,862.45,58.75,,611.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,127.25,100,,,Fee Schedule,100% of ASC Tier Groupings,689.96,47,,824.008,Percent of Total Billed Charges,47% of Total Billed charges,127.25,100,,,Fee Schedule,100% ASC Tier Groupings,689.96,47,,824.008,Percent of Total Billed Charges,47% of Total Billed Charges,962.78,160,,,Fee Schedule,160% of UHC fee schedule,199.65,115,,4.512,Fee Schedule,115% of CMS OPPS Rate,199.65,115,,25.944,Fee Schedule,115% of CMS OPPS Rate,127.25,962.78,
CT UPPER EX RT W/O,3050004,CDM,352,RC,73200,HCPCS,Outpatient,,,1301.00,1301.00,RT,764.34,58.75,,919.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,764.34,58.75,,919.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,629.81,48.41,,454.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,611.47,47,,441.312,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,764.34,58.75,,919.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,611.47,47,,441.312,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,611.47,47,,441.312,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,160.87,115,,25.944,Fee Schedule,115% of CMS OPPS Rate,160.87,115,,4.888,Fee Schedule,115% of CMS OPPS Rate,45.83,764.34,
CT LOWER EX W+W/O RT,3050028,CDM,352,RC,73702,HCPCS,Outpatient,,,1779.00,1779.00,RT,1045.16,58.75,,722.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,1045.16,58.75,,722.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,861.21,48.41,,383.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,3.96,fee Schedule,100% of BCBS fee schedule,174.94,100,,12.24,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,836.13,47,,372.24,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,12.24,Fee Schedule,100% of BCBS PPO fee schedule,1045.16,58.75,,722.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,836.13,47,,372.24,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,836.13,47,,372.24,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,195.48,115,,4.888,Fee Schedule,115% of CMS OPPS Rate,195.48,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,75.19,1045.16,
CT CERVCL SPINEW/O,3050034,CDM,352,RC,72125,HCPCS,Outpatient,,,1257.30,1257.30,,738.66,58.75,,806.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,738.66,58.75,,806.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,608.66,48.41,,383.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,7.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,590.93,47,,372.24,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,7.92,Fee Schedule,100% of BCBS PPO fee schedule,738.66,58.75,,806.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,590.93,47,,372.24,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,590.93,47,,372.24,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,131.25,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,131.25,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,45.83,738.66,
CT THORACIC SPINE W/,3050035,CDM,352,RC,72129,HCPCS,Outpatient,,,1461.00,1461.00,,858.34,58.75,,686.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,858.34,58.75,,686.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,707.27,48.41,,329.192,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,14.4,fee Schedule,100% of BCBS fee schedule,174.94,100,,10.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,686.67,47,,319.6,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,10.08,Fee Schedule,100% of BCBS PPO fee schedule,858.34,58.75,,686.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,686.67,47,,319.6,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,686.67,47,,319.6,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,171.04,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,171.04,115,,5.264,Fee Schedule,115% of CMS OPPS Rate,75.19,858.34,
HEAD CT W/O CONTRST,3050039,CDM,351,RC,70450,HCPCS,Outpatient,,,1562.20,1562.20,,917.79,58.75,,722.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,917.79,58.75,,722.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,756.26,48.41,,274.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,10.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,734.23,47,,266.96,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,10.08,Fee Schedule,100% of BCBS PPO fee schedule,917.79,58.75,,722.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,734.23,47,,266.96,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,734.23,47,,266.96,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,107.76,115,,5.264,Fee Schedule,115% of CMS OPPS Rate,107.76,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,45.83,917.79,
CT C-SP W/CONTRAST,3050042,CDM,352,RC,72126,HCPCS,Outpatient,,,1334.00,1334.00,,783.73,58.75,,776.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,783.73,58.75,,776.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,645.79,48.41,,296.272,Percent of Total Billed Charges,48.41% of Total Billed Charges,366.59,100,,3.6,fee Schedule,100% of BCBS fee schedule,366.59,100,,7.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,626.98,47,,287.64,Percent of Total Billed Charges,47% of Total Billed Charges,366.59,100,,7.92,Fee Schedule,100% of BCBS PPO fee schedule,783.73,58.75,,776.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.13,100,,,Fee Schedule,100% of ASC Tier Groupings,626.98,47,,287.64,Percent of Total Billed Charges,47% of Total Billed charges,96.13,100,,,Fee Schedule,100% ASC Tier Groupings,626.98,47,,287.64,Percent of Total Billed Charges,47% of Total Billed Charges,962.78,160,,,Fee Schedule,160% of UHC fee schedule,169.57,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,169.57,115,,3.008,Fee Schedule,115% of CMS OPPS Rate,96.13,962.78,
CT ABDOMEN W&W/O CONTRST,3050044,CDM,352,RC,74170,HCPCS,Outpatient,,,2075.70,2075.70,,1219.47,58.75,,845.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,1219.47,58.75,,845.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,1004.85,48.41,,406.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,3.6,fee Schedule,100% of BCBS fee schedule,174.94,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,975.58,47,,394.8,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,1219.47,58.75,,845.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,975.58,47,,394.8,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,975.58,47,,394.8,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,258.67,115,,3.008,Fee Schedule,115% of CMS OPPS Rate,258.67,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,75.19,1219.47,
CT UPPER EX W+W/O RT,3050053,CDM,352,RC,73202,HCPCS,Outpatient,,,1652.00,1652.00,RT,970.55,58.75,,686.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,970.55,58.75,,686.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,799.73,48.41,,261.416,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,10.08,fee Schedule,100% of BCBS fee schedule,174.94,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,776.44,47,,253.8,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,970.55,58.75,,686.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,776.44,47,,253.8,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,776.44,47,,253.8,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,244.94,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,244.94,115,,6.392,Fee Schedule,115% of CMS OPPS Rate,75.19,970.55,
CT LUMBAR SPINEW/O,3050055,CDM,352,RC,72131,HCPCS,Outpatient,,,1607.00,1607.00,,944.11,58.75,,592.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,944.11,58.75,,592.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,777.95,48.41,,261.416,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,18.72,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,755.29,47,,253.8,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,944.11,58.75,,592.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,755.29,47,,253.8,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,755.29,47,,253.8,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,130.61,115,,6.392,Fee Schedule,115% of CMS OPPS Rate,130.61,115,,4.136,Fee Schedule,115% of CMS OPPS Rate,45.83,944.11,
HEAD-CT W/CONTRAST,3060002,CDM,351,RC,70460,HCPCS,Outpatient,,,1220.00,1220.00,,716.75,58.75,,716.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,716.75,58.75,,716.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,590.6,48.41,,472.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,20.88,fee Schedule,100% of BCBS fee schedule,174.94,100,,14.4,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,573.4,47,,458.72,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,14.4,Fee Schedule,100% of BCBS PPO fee schedule,716.75,58.75,,716.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,573.4,47,,458.72,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,573.4,47,,458.72,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,149.59,115,,4.136,Fee Schedule,115% of CMS OPPS Rate,149.59,115,,5.264,Fee Schedule,115% of CMS OPPS Rate,75.19,716.75,
HEAD CT W&W/O CNTRST,3060007,CDM,351,RC,70470,HCPCS,Outpatient,,,1845.25,1845.25,,1084.08,58.75,,626.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,1084.08,58.75,,626.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,893.29,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,46.08,fee Schedule,100% of BCBS fee schedule,174.94,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,867.27,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,1084.08,58.75,,626.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,867.27,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,867.27,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,174.5,115,,5.264,Fee Schedule,115% of CMS OPPS Rate,174.5,115,,5.264,Fee Schedule,115% of CMS OPPS Rate,75.19,1084.08,
CT CHEST W/CNTRST,3060016,CDM,352,RC,71260,HCPCS,Outpatient,,,1173.70,1173.70,,689.55,58.75,,538.736,Percent of Total Billed Charges,58.75% of Total Billed Charges,689.55,58.75,,538.736,Percent of Total Billed Charges,58.75% of Total Billed Charges,568.19,48.41,,38.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,3.6,fee Schedule,100% of BCBS fee schedule,174.94,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,551.64,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,689.55,58.75,,538.736,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,551.64,47,,37.6,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,551.64,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,167.66,115,,5.264,Fee Schedule,115% of CMS OPPS Rate,167.66,115,,4.136,Fee Schedule,115% of CMS OPPS Rate,75.19,689.55,
CT CHEST W/O CNTRST,3060018,CDM,352,RC,71250,HCPCS,Outpatient,,,1861.00,1861.00,,1093.34,58.75,,90.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,1093.34,58.75,,90.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,900.91,48.41,,67.384,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,874.67,47,,65.424,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,1093.34,58.75,,90.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,874.67,47,,65.424,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,874.67,47,,65.424,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,134.41,115,,4.136,Fee Schedule,115% of CMS OPPS Rate,134.41,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,45.83,1093.34,
CT ABDOMEN W/O CNTRST,3060020,CDM,352,RC,74150,HCPCS,Outpatient,,,1398.00,1398.00,,821.33,58.75,,79.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,821.33,58.75,,79.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,676.77,48.41,,76.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.96,fee Schedule,100% of BCBS fee schedule,107.6,100,,10.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,657.06,47,,74.448,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,10.08,Fee Schedule,100% of BCBS PPO fee schedule,821.33,58.75,,79.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,657.06,47,,74.448,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,657.06,47,,74.448,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,138.18,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,138.18,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,45.83,821.33,
CT ABDOMENW/CNTRST,3060021,CDM,352,RC,74160,HCPCS,Outpatient,,,1461.00,1461.00,,858.34,58.75,,95.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,858.34,58.75,,95.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,707.27,48.41,,90.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,5.04,fee Schedule,100% of BCBS fee schedule,174.94,100,,18.72,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,686.67,47,,87.984,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,18.72,Fee Schedule,100% of BCBS PPO fee schedule,858.34,58.75,,95.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,686.67,47,,87.984,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,686.67,47,,87.984,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,230.16,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,230.16,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,75.19,858.34,
CT LO EX W/CONTRT RT,3060027,CDM,352,RC,73701,HCPCS,Outpatient,,,1334.00,1334.00,RT,783.73,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,783.73,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,645.79,48.41,,103.792,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,23.76,fee Schedule,100% of BCBS fee schedule,174.94,100,,20.88,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,626.98,47,,100.768,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,20.88,Fee Schedule,100% of BCBS PPO fee schedule,783.73,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,626.98,47,,100.768,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,626.98,47,,100.768,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,167.34,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,167.34,115,,7.52,Fee Schedule,115% of CMS OPPS Rate,75.19,783.73,
CT LO EX W/O CONT RT,3060038,CDM,352,RC,73700,HCPCS,Outpatient,,,1301.00,1301.00,RT,764.34,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,764.34,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,629.81,48.41,,22.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,46.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,611.47,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,46.08,Fee Schedule,100% of BCBS PPO fee schedule,764.34,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,611.47,47,,21.432,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,611.47,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,130.93,115,,7.52,Fee Schedule,115% of CMS OPPS Rate,130.93,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,45.83,764.34,
CHEST CT W&W/O CONST,3060056,CDM,352,RC,71270,HCPCS,Outpatient,,,1956.90,1956.90,,1149.68,58.75,,78.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,1149.68,58.75,,78.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,947.34,48.41,,35.608,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,3.6,fee Schedule,100% of BCBS fee schedule,174.94,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,919.74,47,,34.576,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,1149.68,58.75,,78.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,919.74,47,,34.576,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,919.74,47,,34.576,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,196.47,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,196.47,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,75.19,1149.68,
CT THOR SPINE W/O,3061009,CDM,352,RC,72128,HCPCS,Outpatient,,,1538.00,1538.00,,903.58,58.75,,90.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,903.58,58.75,,90.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,744.55,48.41,,18.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,32.4,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,722.86,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,903.58,58.75,,90.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,722.86,47,,17.672,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,722.86,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,130.93,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,130.93,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,45.83,903.58,
CT PELVIS W&W/OCNTR,3061011,CDM,352,RC,72194,HCPCS,Outpatient,,,1715.00,1715.00,,1007.56,58.75,,78.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,1007.56,58.75,,78.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,830.23,48.41,,36.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,3.6,fee Schedule,100% of BCBS fee schedule,174.94,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,806.05,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,1007.56,58.75,,78.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,806.05,47,,35.344,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,806.05,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,249.23,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,249.23,115,,5.264,Fee Schedule,115% of CMS OPPS Rate,75.19,1007.56,
CT PELVIS W/CNTRST,3061012,CDM,352,RC,72193,HCPCS,Outpatient,,,1461.00,1461.00,,858.34,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,858.34,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,707.27,48.41,,26.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,10.08,fee Schedule,100% of BCBS fee schedule,174.94,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,686.67,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,858.34,58.75,,71.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,686.67,47,,25.944,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,686.67,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,225.88,115,,5.264,Fee Schedule,115% of CMS OPPS Rate,225.88,115,,9.776,Fee Schedule,115% of CMS OPPS Rate,75.19,858.34,
CT PELVIS W/O CNTRST,3061013,CDM,352,RC,72192,HCPCS,Outpatient,,,1538.00,1538.00,,903.58,58.75,,78.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,903.58,58.75,,78.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,744.55,48.41,,16.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,10.08,fee Schedule,100% of BCBS fee schedule,107.6,100,,23.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,722.86,47,,16.128,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,23.76,Fee Schedule,100% of BCBS PPO fee schedule,903.58,58.75,,78.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,722.86,47,,16.128,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,722.86,47,,16.128,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,134.47,115,,9.776,Fee Schedule,115% of CMS OPPS Rate,134.47,115,,10.904,Fee Schedule,115% of CMS OPPS Rate,45.83,903.58,
CT THO SPINE W/WO,3061016,CDM,351,RC,72130,HCPCS,Outpatient,,,1652.00,1652.00,,970.55,58.75,,65.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,970.55,58.75,,65.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,799.73,48.41,,40.664,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,4.32,fee Schedule,100% of BCBS fee schedule,174.94,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,776.44,47,,39.48,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,970.55,58.75,,65.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,776.44,47,,39.48,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,776.44,47,,39.48,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,199.13,115,,10.904,Fee Schedule,115% of CMS OPPS Rate,199.13,115,,24.064,Fee Schedule,115% of CMS OPPS Rate,75.19,970.55,
CT NECK W&W/O CNTRST,3061017,CDM,351,RC,70492,HCPCS,Outpatient,,,1799.00,1799.00,,1056.91,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,1056.91,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,870.9,48.41,,15.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,5.04,fee Schedule,100% of BCBS fee schedule,174.94,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,845.53,47,,15.416,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,1056.91,58.75,,85.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,845.53,47,,15.416,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,845.53,47,,15.416,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,222.26,115,,24.064,Fee Schedule,115% of CMS OPPS Rate,222.26,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,75.19,1056.91,
CT NECK W/CONTRAST,3061018,CDM,351,RC,70491,HCPCS,Outpatient,,,1461.00,1461.00,,858.34,58.75,,538.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,858.34,58.75,,538.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,707.27,48.41,,36.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,25.92,fee Schedule,100% of BCBS fee schedule,174.94,100,,32.4,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,686.67,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,32.4,Fee Schedule,100% of BCBS PPO fee schedule,858.34,58.75,,538.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,686.67,47,,35.344,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,686.67,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,185.31,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,185.31,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,75.19,858.34,
CT NECK W/O CONTRAST,3061019,CDM,351,RC,70490,HCPCS,Outpatient,,,1260.80,1260.80,,740.72,58.75,,689.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,740.72,58.75,,689.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,610.35,48.41,,54.992,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,23.76,fee Schedule,100% of BCBS fee schedule,107.6,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,592.58,47,,53.392,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,740.72,58.75,,689.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,592.58,47,,53.392,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,592.58,47,,53.392,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,151.97,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,151.97,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,45.83,740.72,
CT LUMB SPINE W+W/O,3061021,CDM,352,RC,72133,HCPCS,Outpatient,,,1525.00,1525.00,,895.94,58.75,,716.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,895.94,58.75,,716.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,738.25,48.41,,75.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,7.2,fee Schedule,100% of BCBS fee schedule,174.94,100,,10.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,716.75,47,,73.32,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,10.08,Fee Schedule,100% of BCBS PPO fee schedule,895.94,58.75,,716.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,716.75,47,,73.32,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,716.75,47,,73.32,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,197.21,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,197.21,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,75.19,895.94,
CT LUMBAR W/CONTRAST,3061100,CDM,352,RC,72132,HCPCS,Outpatient,,,1334.00,1334.00,,783.73,58.75,,567.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,783.73,58.75,,567.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,645.79,48.41,,90.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,366.59,100,,5.76,fee Schedule,100% of BCBS fee schedule,366.59,100,,10.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,626.98,47,,87.984,Percent of Total Billed Charges,47% of Total Billed Charges,366.59,100,,10.08,Fee Schedule,100% of BCBS PPO fee schedule,783.73,58.75,,567.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.13,100,,,Fee Schedule,100% of ASC Tier Groupings,626.98,47,,87.984,Percent of Total Billed Charges,47% of Total Billed charges,96.13,100,,,Fee Schedule,100% ASC Tier Groupings,626.98,47,,87.984,Percent of Total Billed Charges,47% of Total Billed Charges,962.78,160,,,Fee Schedule,160% of UHC fee schedule,170.21,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,170.21,115,,12.408,Fee Schedule,115% of CMS OPPS Rate,96.13,962.78,
CT SINUS,3061102,CDM,350,RC,70486,HCPCS,Outpatient,,,1146.25,1146.25,,673.42,58.75,,788.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,673.42,58.75,,788.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,554.9,48.41,,48.8,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,4.32,fee Schedule,100% of BCBS fee schedule,107.6,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,538.74,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,673.42,58.75,,788.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,538.74,47,,47.376,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,538.74,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,128.55,115,,12.408,Fee Schedule,115% of CMS OPPS Rate,128.55,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,45.83,673.42,
UPPER EXTREM INFANT,3061103,CDM,320,RC,73092,HCPCS,Outpatient,,,193.00,193.00,,113.39,58.75,,776.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,113.39,58.75,,776.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,93.43,48.41,,15.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,3.6,fee Schedule,100% of BCBS fee schedule,107.6,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,90.71,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,113.39,58.75,,776.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,90.71,47,,15.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,90.71,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,30.65,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.65,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,30.65,284.64,
FOOT 2 VIEWS RIGHT,3061104,CDM,320,RC,73620,HCPCS,Outpatient,,,169.00,169.00,RT,99.29,58.75,,672.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,99.29,58.75,,672.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,81.81,48.41,,54.608,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,25.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,79.43,47,,53.016,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,25.92,Fee Schedule,100% of BCBS PPO fee schedule,99.29,58.75,,672.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,79.43,47,,53.016,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,79.43,47,,53.016,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,27.76,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,27.76,115,,16.92,Fee Schedule,115% of CMS OPPS Rate,27.76,211.49,
TMJ'S BILAT,3061105,CDM,320,RC,70330,HCPCS,Outpatient,,,203.00,203.00,,119.26,58.75,,626.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,119.26,58.75,,626.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,98.27,48.41,,19.6,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,9.36,fee Schedule,100% of BCBS fee schedule,76.62,100,,23.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,95.41,47,,19.024,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,23.76,Fee Schedule,100% of BCBS PPO fee schedule,119.26,58.75,,626.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,95.41,47,,19.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,95.41,47,,19.024,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,51.85,115,,16.92,Fee Schedule,115% of CMS OPPS Rate,51.85,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,51.85,211.49,
STERNOCLIVCULAR3V,3061106,CDM,320,RC,71130,HCPCS,Outpatient,,,165.00,165.00,,96.94,58.75,,776.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.94,58.75,,776.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.88,48.41,,53.248,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,7.2,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,77.55,47,,51.704,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,7.2,Fee Schedule,100% of BCBS PPO fee schedule,96.94,58.75,,776.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.55,47,,51.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,77.55,47,,51.704,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,40.24,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,40.24,115,,5.264,Fee Schedule,115% of CMS OPPS Rate,40.24,211.49,
CHEST W/APICAL LORDO,3061107,CDM,320,RC,71047,HCPCS,Outpatient,,,191.00,191.00,,112.21,58.75,,611.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,112.21,58.75,,611.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,92.46,48.41,,20.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.96,fee Schedule,100% of BCBS fee schedule,76.62,100,,5.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,89.77,47,,20.024,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,5.76,Fee Schedule,100% of BCBS PPO fee schedule,112.21,58.75,,611.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,89.77,47,,20.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,89.77,47,,20.024,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,41.46,115,,5.264,Fee Schedule,115% of CMS OPPS Rate,41.46,115,,5.264,Fee Schedule,115% of CMS OPPS Rate,41.46,211.49,
WRIST 2 VIEWS RIGHT,3061108,CDM,320,RC,73100,HCPCS,Outpatient,,,168.00,168.00,RT,98.7,58.75,,626.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,98.7,58.75,,626.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,81.33,48.41,,33.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,78.96,47,,32.672,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,98.7,58.75,,626.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,78.96,47,,32.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,78.96,47,,32.672,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,32.88,115,,5.264,Fee Schedule,115% of CMS OPPS Rate,32.88,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,32.88,211.49,
LOWER EXTR INFANT 2V,3061109,CDM,320,RC,73592,HCPCS,Outpatient,,,192.00,192.00,,112.8,58.75,,836.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,112.8,58.75,,836.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,92.95,48.41,,60.416,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,59.04,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,90.24,47,,58.656,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,112.8,58.75,,836.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,90.24,47,,58.656,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,90.24,47,,58.656,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,30.65,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,30.65,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,30.65,211.49,
ELBOW 3 VIEWS RIGHT,3061111,CDM,320,RC,73080,HCPCS,Outpatient,,,168.00,168.00,RT,98.7,58.75,,280.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,98.7,58.75,,280.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,81.33,48.41,,10.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,63.36,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,78.96,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,98.7,58.75,,280.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,78.96,47,,10.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,78.96,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,31.98,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,31.98,115,,13.536,Fee Schedule,115% of CMS OPPS Rate,31.98,211.49,
MANDIBLE LESS 4VIEW,3061112,CDM,320,RC,70100,HCPCS,Outpatient,,,152.00,152.00,,89.3,58.75,,291.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.3,58.75,,291.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.58,48.41,,49.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,74.88,fee Schedule,100% of BCBS fee schedule,76.62,100,,9.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,71.44,47,,48.448,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,9.36,Fee Schedule,100% of BCBS PPO fee schedule,89.3,58.75,,291.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,71.44,47,,48.448,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,71.44,47,,48.448,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,37.79,115,,13.536,Fee Schedule,115% of CMS OPPS Rate,37.79,115,,12.408,Fee Schedule,115% of CMS OPPS Rate,37.79,211.49,
THORACOLUMBAR STAND,3061113,CDM,320,RC,72081,HCPCS,Outpatient,,,167.20,167.20,,98.23,58.75,,1030.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,98.23,58.75,,1030.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,80.94,48.41,,50.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,4.32,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,78.58,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,98.23,58.75,,1030.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,78.58,47,,48.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,78.58,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,42.37,115,,12.408,Fee Schedule,115% of CMS OPPS Rate,42.37,115,,3.76,Fee Schedule,115% of CMS OPPS Rate,42.37,211.49,
ANKLE 2 VIEWS RIGHT,3061114,CDM,320,RC,73600,HCPCS,Outpatient,,,139.70,139.70,RT,82.07,58.75,,1376.256,Percent of Total Billed Charges,58.75% of Total Billed Charges,82.07,58.75,,1376.256,Percent of Total Billed Charges,58.75% of Total Billed Charges,67.63,48.41,,22.576,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,10.8,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,65.66,47,,21.92,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,82.07,58.75,,1376.256,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,65.66,47,,21.92,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,65.66,47,,21.92,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,31.28,115,,3.76,Fee Schedule,115% of CMS OPPS Rate,31.28,115,,3.008,Fee Schedule,115% of CMS OPPS Rate,31.28,211.49,
SOFT TISSUE NECK,3061115,CDM,320,RC,70360,HCPCS,Outpatient,,,181.50,181.50,,106.63,58.75,,1329.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,106.63,58.75,,1329.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,87.86,48.41,,128.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,85.31,47,,125.208,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,106.63,58.75,,1329.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,85.31,47,,125.208,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,85.31,47,,125.208,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,30.75,115,,3.008,Fee Schedule,115% of CMS OPPS Rate,30.75,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,30.75,211.49,
CT ORBIT/IAC/SELLAWO C,3061117,CDM,351,RC,70480,HCPCS,Outpatient,,,1146.20,1146.20,,673.39,58.75,,1030.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,673.39,58.75,,1030.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,554.88,48.41,,27.496,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,18,fee Schedule,100% of BCBS fee schedule,107.6,100,,59.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,538.71,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,59.04,Fee Schedule,100% of BCBS PPO fee schedule,673.39,58.75,,1030.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,538.71,47,,26.696,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,538.71,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,160.48,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,160.48,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,45.83,673.39,
CT ORBIT/IAC/SELLAW CO,3061118,CDM,351,RC,70481,HCPCS,Outpatient,,,1467.40,1467.40,,862.1,58.75,,551.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,862.1,58.75,,551.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,710.37,48.41,,27.496,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,21.6,fee Schedule,100% of BCBS fee schedule,174.94,100,,63.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,689.68,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,63.36,Fee Schedule,100% of BCBS PPO fee schedule,862.1,58.75,,551.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,689.68,47,,26.696,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,689.68,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,180.62,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,180.62,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,75.19,862.1,
CT ORBIT/IAC/SELL W/WOC,3061119,CDM,351,RC,70482,HCPCS,Outpatient,,,1525.00,1525.00,,895.94,58.75,,465.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,895.94,58.75,,465.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,738.25,48.41,,72.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,17.28,fee Schedule,100% of BCBS fee schedule,174.94,100,,74.88,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,716.75,47,,69.936,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,74.88,Fee Schedule,100% of BCBS PPO fee schedule,895.94,58.75,,465.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,716.75,47,,69.936,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,716.75,47,,69.936,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,210.01,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,210.01,115,,4.888,Fee Schedule,115% of CMS OPPS Rate,75.19,895.94,
CT FACIAL W CONTRAST,3061120,CDM,351,RC,70487,HCPCS,Outpatient,,,1207.00,1207.00,,709.11,58.75,,465.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,709.11,58.75,,465.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,584.31,48.41,,64.44,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,54,fee Schedule,100% of BCBS fee schedule,174.94,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,567.29,47,,62.568,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,709.11,58.75,,465.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,567.29,47,,62.568,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,567.29,47,,62.568,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,153.11,115,,4.888,Fee Schedule,115% of CMS OPPS Rate,153.11,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,75.19,709.11,
CT FACIAL W/WO CONT,3061121,CDM,351,RC,70488,HCPCS,Outpatient,,,1677.50,1677.50,,985.53,58.75,,399.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,985.53,58.75,,399.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,812.08,48.41,,151.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,115.92,fee Schedule,100% of BCBS fee schedule,174.94,100,,10.8,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,788.43,47,,147.016,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,10.8,Fee Schedule,100% of BCBS PPO fee schedule,985.53,58.75,,399.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,788.43,47,,147.016,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,788.43,47,,147.016,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,184.74,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,184.74,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,75.19,985.53,
CT SERV SPINE W/WOCONT,3061122,CDM,352,RC,72127,HCPCS,Outpatient,,,1652.00,1652.00,,970.55,58.75,,333.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,970.55,58.75,,333.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,799.73,48.41,,87.912,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,5.76,fee Schedule,100% of BCBS fee schedule,174.94,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,776.44,47,,85.352,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,970.55,58.75,,333.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,776.44,47,,85.352,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,776.44,47,,85.352,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,196.89,115,,2.072,Fee Schedule,115% of CMS OPPS Rate,196.89,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,75.19,970.55,
CT UPPER EX W/O CONT LT,3061124,CDM,352,RC,73200,HCPCS,Outpatient,,,1430.20,1430.20,LT,840.24,58.75,,359.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,840.24,58.75,,359.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,692.36,48.41,,40.896,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,5.76,fee Schedule,100% of BCBS fee schedule,107.6,100,,18,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,672.19,47,,39.704,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,18,Fee Schedule,100% of BCBS PPO fee schedule,840.24,58.75,,359.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,672.19,47,,39.704,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,672.19,47,,39.704,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,160.87,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,160.87,115,,30.832,Fee Schedule,115% of CMS OPPS Rate,45.83,840.24,
CT UPPER EX W CONT LEFT,3061126,CDM,352,RC,73201,HCPCS,Outpatient,,,1334.00,1334.00,LT,783.73,58.75,,493.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,783.73,58.75,,493.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,645.79,48.41,,91.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,366.59,100,,72,fee Schedule,100% of BCBS fee schedule,366.59,100,,21.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,626.98,47,,89.112,Percent of Total Billed Charges,47% of Total Billed Charges,366.59,100,,21.6,Fee Schedule,100% of BCBS PPO fee schedule,783.73,58.75,,493.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,127.25,100,,,Fee Schedule,100% of ASC Tier Groupings,626.98,47,,89.112,Percent of Total Billed Charges,47% of Total Billed charges,127.25,100,,,Fee Schedule,100% ASC Tier Groupings,626.98,47,,89.112,Percent of Total Billed Charges,47% of Total Billed Charges,962.78,160,,,Fee Schedule,160% of UHC fee schedule,199.65,115,,30.832,Fee Schedule,115% of CMS OPPS Rate,199.65,115,,33.088,Fee Schedule,115% of CMS OPPS Rate,127.25,962.78,
CT UP EX W&W/O CONT LT,3061128,CDM,352,RC,73202,HCPCS,Outpatient,,,1652.00,1652.00,LT,970.55,58.75,,317.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,970.55,58.75,,317.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,799.73,48.41,,63.416,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,28.8,fee Schedule,100% of BCBS fee schedule,174.94,100,,17.28,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,776.44,47,,61.568,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,17.28,Fee Schedule,100% of BCBS PPO fee schedule,970.55,58.75,,317.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,776.44,47,,61.568,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,776.44,47,,61.568,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,244.94,115,,33.088,Fee Schedule,115% of CMS OPPS Rate,244.94,115,,39.104,Fee Schedule,115% of CMS OPPS Rate,75.19,970.55,
CT LO EX W/O CONT LT,3061130,CDM,352,RC,73700,HCPCS,Outpatient,,,1301.00,1301.00,LT,764.34,58.75,,317.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,764.34,58.75,,317.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,629.81,48.41,,43.664,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.6,100,,28.8,fee Schedule,100% of BCBS fee schedule,107.6,100,,54,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,611.47,47,,42.392,Percent of Total Billed Charges,47% of Total Billed Charges,107.6,100,,54,Fee Schedule,100% of BCBS PPO fee schedule,764.34,58.75,,317.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,100,,,Fee Schedule,100% of ASC Tier Groupings,611.47,47,,42.392,Percent of Total Billed Charges,47% of Total Billed charges,45.83,100,,,Fee Schedule,100% ASC Tier Groupings,611.47,47,,42.392,Percent of Total Billed Charges,47% of Total Billed Charges,284.64,160,,,Fee Schedule,160% of UHC fee schedule,130.93,115,,39.104,Fee Schedule,115% of CMS OPPS Rate,130.93,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,45.83,764.34,
CT LO EX W/ CONT LT,3061132,CDM,352,RC,73701,HCPCS,Outpatient,,,1334.00,1334.00,LT,783.73,58.75,,573.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,783.73,58.75,,573.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,645.79,48.41,,17.04,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,47.52,fee Schedule,100% of BCBS fee schedule,174.94,100,,115.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,626.98,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,115.92,Fee Schedule,100% of BCBS PPO fee schedule,783.73,58.75,,573.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,626.98,47,,16.544,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,626.98,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,167.34,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,167.34,115,,5.64,Fee Schedule,115% of CMS OPPS Rate,75.19,783.73,
CT LO EX W&W/O LEFT,3061134,CDM,352,RC,73702,HCPCS,Outpatient,,,1779.00,1779.00,LT,1045.16,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,1045.16,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,861.21,48.41,,95.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,41.04,fee Schedule,100% of BCBS fee schedule,174.94,100,,5.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,836.13,47,,93.176,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,5.76,Fee Schedule,100% of BCBS PPO fee schedule,1045.16,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,836.13,47,,93.176,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,836.13,47,,93.176,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,195.48,115,,5.64,Fee Schedule,115% of CMS OPPS Rate,195.48,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,75.19,1045.16,
CT LIM F/UP LOCAL,3061136,CDM,350,RC,76380,HCPCS,Outpatient,,,597.00,597.00,,350.74,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,350.74,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,289.01,48.41,,27.112,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,5.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,280.59,47,,26.32,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,5.76,Fee Schedule,100% of BCBS PPO fee schedule,350.74,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,280.59,47,,26.32,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,280.59,47,,26.32,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,131.65,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,131.65,115,,9.4,Fee Schedule,115% of CMS OPPS Rate,76.62,350.74,
CT BONE DENSITYAXIL,3061137,CDM,350,RC,77078,HCPCS,Outpatient,,,621.00,621.00,,364.84,58.75,,81.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,364.84,58.75,,81.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,300.63,48.41,,20.448,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.62,100,,3.6,fee Schedule,100% of BCBS fee schedule,76.62,100,,72,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,291.87,47,,19.856,Percent of Total Billed Charges,47% of Total Billed Charges,76.62,100,,72,Fee Schedule,100% of BCBS PPO fee schedule,364.84,58.75,,81.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.05,100,,,Fee Schedule,100% of ASC Tier Groupings,291.87,47,,19.856,Percent of Total Billed Charges,47% of Total Billed charges,34.05,100,,,Fee Schedule,100% ASC Tier Groupings,291.87,47,,19.856,Percent of Total Billed Charges,47% of Total Billed Charges,211.49,160,,,Fee Schedule,160% of UHC fee schedule,97.01,115,,9.4,Fee Schedule,115% of CMS OPPS Rate,97.01,115,,11.28,Fee Schedule,115% of CMS OPPS Rate,34.05,364.84,
CT ABD/PELV W CONTRS,3061138,CDM,352,RC,74177,HCPCS,Outpatient,,,2191.50,2191.50,,1287.51,58.75,,93.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,1287.51,58.75,,93.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,1060.91,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,366.59,100,,53.28,fee Schedule,100% of BCBS fee schedule,366.59,100,,28.8,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,1030.01,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,366.59,100,,28.8,Fee Schedule,100% of BCBS PPO fee schedule,1287.51,58.75,,93.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,155.01,100,,,Fee Schedule,100% of ASC Tier Groupings,1030.01,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,155.01,100,,,Fee Schedule,100% ASC Tier Groupings,1030.01,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,962.78,160,,,Fee Schedule,160% of UHC fee schedule,301.94,115,,11.28,Fee Schedule,115% of CMS OPPS Rate,301.94,115,,9.024,Fee Schedule,115% of CMS OPPS Rate,155.01,1287.51,
CT ABD/PELV W/OCONT,3061139,CDM,352,RC,74176,HCPCS,Outpatient,,,2928.20,2928.20,,1720.32,58.75,,109.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,1720.32,58.75,,109.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,1417.54,48.41,,18.976,Percent of Total Billed Charges,48.41% of Total Billed Charges,223.73,100,,9.36,fee Schedule,100% of BCBS fee schedule,223.73,100,,28.8,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,1376.25,47,,18.424,Percent of Total Billed Charges,47% of Total Billed Charges,223.73,100,,28.8,Fee Schedule,100% of BCBS PPO fee schedule,1720.32,58.75,,109.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,87.38,100,,,Fee Schedule,100% of ASC Tier Groupings,1376.25,47,,18.424,Percent of Total Billed Charges,47% of Total Billed charges,87.38,100,,,Fee Schedule,100% ASC Tier Groupings,1376.25,47,,18.424,Percent of Total Billed Charges,47% of Total Billed Charges,601.6,160,,,Fee Schedule,160% of UHC fee schedule,186.61,115,,9.024,Fee Schedule,115% of CMS OPPS Rate,186.61,115,,28.2,Fee Schedule,115% of CMS OPPS Rate,87.38,1720.32,
CT ABD/PELV W/WO CON,3061140,CDM,352,RC,74178,HCPCS,Outpatient,,,2829.75,2829.75,,1662.48,58.75,,125.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,1662.48,58.75,,125.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,1369.88,48.41,,23.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,366.59,100,,136.8,fee Schedule,100% of BCBS fee schedule,366.59,100,,47.52,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,1329.98,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,366.59,100,,47.52,Fee Schedule,100% of BCBS PPO fee schedule,1662.48,58.75,,125.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,155.01,100,,,Fee Schedule,100% of ASC Tier Groupings,1329.98,47,,22.936,Percent of Total Billed Charges,47% of Total Billed charges,155.01,100,,,Fee Schedule,100% ASC Tier Groupings,1329.98,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,962.78,160,,,Fee Schedule,160% of UHC fee schedule,338,115,,28.2,Fee Schedule,115% of CMS OPPS Rate,338,115,,60.536,Fee Schedule,115% of CMS OPPS Rate,155.01,1662.48,
CTA ABD/Pel W/WO Cont.,3061141,CDM,352,RC,74174,HCPCS,Outpatient,,,2191.50,2191.50,,1287.51,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,1287.51,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,1060.91,48.41,,24.28,Percent of Total Billed Charges,48.41% of Total Billed Charges,366.59,100,,30.24,fee Schedule,100% of BCBS fee schedule,366.59,100,,41.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,1030.01,47,,23.576,Percent of Total Billed Charges,47% of Total Billed Charges,366.59,100,,41.04,Fee Schedule,100% of BCBS PPO fee schedule,1287.51,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,155.01,100,,,Fee Schedule,100% of ASC Tier Groupings,1030.01,47,,23.576,Percent of Total Billed Charges,47% of Total Billed charges,155.01,100,,,Fee Schedule,100% ASC Tier Groupings,1030.01,47,,23.576,Percent of Total Billed Charges,47% of Total Billed Charges,962.78,160,,,Fee Schedule,160% of UHC fee schedule,379.42,115,,60.536,Fee Schedule,115% of CMS OPPS Rate,379.42,115,,3.008,Fee Schedule,115% of CMS OPPS Rate,155.01,1287.51,
CT CHEST (PE PROTOCOL),3061142,CDM,352,RC,71275,HCPCS,Outpatient,,,1173.70,1173.70,,689.55,58.75,,43.216,Percent of Total Billed Charges,58.75% of Total Billed Charges,689.55,58.75,,43.216,Percent of Total Billed Charges,58.75% of Total Billed Charges,568.19,48.41,,24.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,5.04,fee Schedule,100% of BCBS fee schedule,174.94,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,551.64,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,689.55,58.75,,43.216,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,551.64,47,,24.064,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,551.64,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,282.62,115,,3.008,Fee Schedule,115% of CMS OPPS Rate,282.62,115,,3.008,Fee Schedule,115% of CMS OPPS Rate,75.19,689.55,
CTA CAROTIDS,3061144,CDM,352,RC,70498,HCPCS,Outpatient,,,990.00,990.00,,581.63,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,581.63,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,479.26,48.41,,17.04,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,4.32,fee Schedule,100% of BCBS fee schedule,174.94,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,465.3,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,581.63,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,465.3,47,,16.544,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,465.3,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,276.75,115,,3.008,Fee Schedule,115% of CMS OPPS Rate,276.75,115,,37.6,Fee Schedule,115% of CMS OPPS Rate,75.19,581.63,
CTA HEAD,30611443,CDM,351,RC,70496,HCPCS,Outpatient,,,990.00,990.00,,581.63,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,581.63,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,479.26,48.41,,56.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,4.32,fee Schedule,100% of BCBS fee schedule,174.94,100,,53.28,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,465.3,47,,55.16,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,53.28,Fee Schedule,100% of BCBS PPO fee schedule,581.63,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,465.3,47,,55.16,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,465.3,47,,55.16,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,277.07,115,,37.6,Fee Schedule,115% of CMS OPPS Rate,277.07,115,,15.04,Fee Schedule,115% of CMS OPPS Rate,75.19,581.63,
CTA CHEST AORTA F/U,3061145,CDM,352,RC,71275,HCPCS,Outpatient,,,850.00,850.00,,499.38,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,499.38,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,411.49,48.41,,25.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,3.6,fee Schedule,100% of BCBS fee schedule,174.94,100,,9.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,399.5,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,9.36,Fee Schedule,100% of BCBS PPO fee schedule,499.38,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,399.5,47,,24.816,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,399.5,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,282.62,115,,15.04,Fee Schedule,115% of CMS OPPS Rate,282.62,115,,15.04,Fee Schedule,115% of CMS OPPS Rate,75.19,499.38,
CTA UPPER EXT UNILATERAL,3061146,CDM,352,RC,73206,HCPCS,Outpatient,,,710.00,710.00,,417.13,58.75,,20.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,417.13,58.75,,20.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,343.71,48.41,,20.448,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,3.6,fee Schedule,100% of BCBS fee schedule,174.94,100,,136.8,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,333.7,47,,19.856,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,136.8,Fee Schedule,100% of BCBS PPO fee schedule,417.13,58.75,,20.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,333.7,47,,19.856,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,333.7,47,,19.856,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,297.16,115,,15.04,Fee Schedule,115% of CMS OPPS Rate,297.16,115,,24.816,Fee Schedule,115% of CMS OPPS Rate,75.19,467.02,
CTA LOWER EXT UNILATERAL,3061147,CDM,352,RC,73706,HCPCS,Outpatient,,,765.00,765.00,,449.44,58.75,,49.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,449.44,58.75,,49.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,370.34,48.41,,45.928,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,9.36,fee Schedule,100% of BCBS fee schedule,174.94,100,,30.24,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,359.55,47,,44.592,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,30.24,Fee Schedule,100% of BCBS PPO fee schedule,449.44,58.75,,49.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,359.55,47,,44.592,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,359.55,47,,44.592,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,322.58,115,,24.816,Fee Schedule,115% of CMS OPPS Rate,322.58,115,,21.432,Fee Schedule,115% of CMS OPPS Rate,75.19,467.02,
CTA ABD/PEL AORTA,3061148,CDM,352,RC,74174,HCPCS,Outpatient,,,1050.00,1050.00,,616.88,58.75,,19.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,616.88,58.75,,19.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,508.31,48.41,,57.976,Percent of Total Billed Charges,48.41% of Total Billed Charges,366.59,100,,8.64,fee Schedule,100% of BCBS fee schedule,366.59,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,493.5,47,,56.288,Percent of Total Billed Charges,47% of Total Billed Charges,366.59,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,616.88,58.75,,19.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,155.01,100,,,Fee Schedule,100% of ASC Tier Groupings,493.5,47,,56.288,Percent of Total Billed Charges,47% of Total Billed charges,155.01,100,,,Fee Schedule,100% ASC Tier Groupings,493.5,47,,56.288,Percent of Total Billed Charges,47% of Total Billed Charges,962.78,160,,,Fee Schedule,160% of UHC fee schedule,379.42,115,,21.432,Fee Schedule,115% of CMS OPPS Rate,379.42,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,155.01,962.78,
CTA KIDNEY/RENAL,3061149,CDM,352,RC,74175,HCPCS,Outpatient,,,675.00,675.00,,396.56,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,396.56,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,326.77,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,3.6,fee Schedule,100% of BCBS fee schedule,174.94,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,317.25,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,396.56,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,317.25,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,317.25,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,305.65,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,305.65,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,75.19,467.02,
CTA LIVER,3061150,CDM,352,RC,74175,HCPCS,Outpatient,,,675.00,675.00,,396.56,58.75,,66.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,396.56,58.75,,66.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,326.77,48.41,,20.024,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,4.32,fee Schedule,100% of BCBS fee schedule,174.94,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,317.25,47,,19.44,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,396.56,58.75,,66.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.19,100,,,Fee Schedule,100% of ASC Tier Groupings,317.25,47,,19.44,Percent of Total Billed Charges,47% of Total Billed charges,75.19,100,,,Fee Schedule,100% ASC Tier Groupings,317.25,47,,19.44,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,305.65,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,305.65,115,,27.824,Fee Schedule,115% of CMS OPPS Rate,75.19,467.02,
CTA FEMORAL RUNOFF,3061151,CDM,352,RC,75635,HCPCS,Outpatient,,,1220.00,1220.00,,716.75,58.75,,91.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,716.75,58.75,,91.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,590.6,48.41,,21.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,174.94,100,,30.24,fee Schedule,100% of BCBS fee schedule,174.94,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,573.4,47,,20.928,Percent of Total Billed Charges,47% of Total Billed Charges,174.94,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,716.75,58.75,,91.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,573.4,47,,20.928,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,573.4,47,,20.928,Percent of Total Billed Charges,47% of Total Billed Charges,467.02,160,,,Fee Schedule,160% of UHC fee schedule,410.54,115,,27.824,Fee Schedule,115% of CMS OPPS Rate,410.54,115,,4.888,Fee Schedule,115% of CMS OPPS Rate,174.94,716.75,
COMPLIMENT C3,4010019,CDM,302,RC,86160,HCPCS,Outpatient,,,32.00,32.00,,18.8,58.75,,109.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,109.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,34.464,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.66,100,,4.32,fee Schedule,100% of BCBS fee schedule,14.66,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,15.04,47,,33.464,Percent of Total Billed Charges,47% of Total Billed Charges,14.66,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,18.8,58.75,,109.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,33.464,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,33.464,Percent of Total Billed Charges,47% of Total Billed Charges,9.72,90,,,Fee Schedule,90% of UHC fee schedule,15.04,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,47,,71.44,Percent of Total Billed Charges,47% of Total Billed Charges,9.72,18.8,
THROAT CULTURE,4010028,CDM,306,RC,87070,HCPCS,Outpatient,,,100.00,100.00,,58.75,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.75,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.41,48.41,,45.312,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.53,100,,3.6,fee Schedule,100% of BCBS fee schedule,10.53,100,,9.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,47,47,,43.992,Percent of Total Billed Charges,47% of Total Billed Charges,10.53,100,,9.36,Fee Schedule,100% of BCBS PPO fee schedule,58.75,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47,47,,43.992,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47,47,,43.992,Percent of Total Billed Charges,47% of Total Billed Charges,6.98,90,,,Fee Schedule,90% of UHC fee schedule,47,47,,71.44,Percent of Total Billed Charges,47% of Total Billed Charges,47,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,6.98,58.75,
BLOOD TYPE ABO,4011002,CDM,302,RC,86900,HCPCS,Outpatient,,,174.00,174.00,,102.23,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,102.23,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.23,48.41,,19.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,99.2,100,,3.6,fee Schedule,100% of BCBS fee schedule,99.2,100,,8.64,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,81.78,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,99.2,100,,8.64,Fee Schedule,100% of BCBS PPO fee schedule,102.23,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,81.78,47,,19.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,81.78,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,2.42,90,,,Fee Schedule,90% of UHC fee schedule,81.78,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,81.78,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.42,102.23,
ANTIBODY ID AHG,4011010,CDM,390,RC,86077,HCPCS,Outpatient,,,198.00,198.00,,116.33,58.75,,66.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,116.33,58.75,,66.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,95.85,48.41,,43.376,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.91,100,,7.92,fee Schedule,100% of BCBS fee schedule,20.91,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,93.06,47,,42.112,Percent of Total Billed Charges,47% of Total Billed Charges,20.91,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,116.33,58.75,,66.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,93.06,47,,42.112,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,93.06,47,,42.112,Percent of Total Billed Charges,47% of Total Billed Charges,370.44,100,,,Case Rate,Pays based on per visit rate,50.13,115,,2.632,Fee Schedule,115% of CMS OPPS Rate,50.13,115,,2.256,Fee Schedule,115% of CMS OPPS Rate,20.91,370.44,
ANTI-BO SCR INDIRECT,4011013,CDM,302,RC,86850,HCPCS,Outpatient,,,234.00,234.00,,137.48,58.75,,23.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,137.48,58.75,,23.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,113.28,48.41,,15.104,Percent of Total Billed Charges,48.41% of Total Billed Charges,45.01,100,,4.32,fee Schedule,100% of BCBS fee schedule,45.01,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,109.98,47,,14.664,Percent of Total Billed Charges,47% of Total Billed Charges,45.01,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,137.48,58.75,,23.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,109.98,47,,14.664,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,109.98,47,,14.664,Percent of Total Billed Charges,47% of Total Billed Charges,7.91,90,,,Fee Schedule,90% of UHC fee schedule,109.98,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,109.98,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,7.91,137.48,
CROSSMATCH EA UNIT,4011018,CDM,302,RC,86922,HCPCS,Outpatient,,,268.00,268.00,,157.45,58.75,,64.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,157.45,58.75,,64.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,129.74,48.41,,25.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,130.55,100,,20.16,fee Schedule,100% of BCBS fee schedule,130.55,100,,30.24,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,125.96,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,130.55,100,,30.24,Fee Schedule,100% of BCBS PPO fee schedule,157.45,58.75,,64.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,125.96,47,,24.816,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,125.96,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,123.38,90,,,Fee Schedule,90% of UHC fee schedule,125.96,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,125.96,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,123.38,157.45,
BLOOD AUTO CONTROL,4011021,CDM,390,RC,86920,HCPCS,Outpatient,,,57.00,57.00,,33.49,58.75,,25.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.49,58.75,,25.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.59,48.41,,54.608,Percent of Total Billed Charges,48.41% of Total Billed Charges,130.55,100,,37.44,fee Schedule,100% of BCBS fee schedule,130.55,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,26.79,47,,53.016,Percent of Total Billed Charges,47% of Total Billed Charges,130.55,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,33.49,58.75,,25.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,53.016,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.79,47,,53.016,Percent of Total Billed Charges,47% of Total Billed Charges,473.38,100,,,Case Rate,Pays based on per visit rate,26.79,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,26.79,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,26.79,473.38,
COOMBS TEST DIRECT,4011023,CDM,390,RC,86880,HCPCS,Outpatient,,,91.95,91.95,,54.02,58.75,,40.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,54.02,58.75,,40.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.51,48.41,,60.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.42,100,,3.6,fee Schedule,100% of BCBS fee schedule,30.42,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,43.22,47,,58.28,Percent of Total Billed Charges,47% of Total Billed Charges,30.42,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,54.02,58.75,,40.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,43.22,47,,58.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,43.22,47,,58.28,Percent of Total Billed Charges,47% of Total Billed Charges,354.37,100,,,Case Rate,Pays based on per visit rate,43.22,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,43.22,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,30.42,354.37,
DU FACTOR,4011027,CDM,302,RC,86901,HCPCS,Outpatient,,,47.00,47.00,,27.61,58.75,,73.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.61,58.75,,73.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.75,48.41,,46.864,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.42,100,,5.04,fee Schedule,100% of BCBS fee schedule,30.42,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,22.09,47,,45.496,Percent of Total Billed Charges,47% of Total Billed Charges,30.42,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,27.61,58.75,,73.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,45.496,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,22.09,47,,45.496,Percent of Total Billed Charges,47% of Total Billed Charges,2.42,90,,,Fee Schedule,90% of UHC fee schedule,22.09,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,2.42,30.42,
"PHLEBOTOMY,THER",4011031,CDM,940,RC,99195,HCPCS,Outpatient,,,94.00,94.00,,55.23,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,55.23,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.51,48.41,,51.024,Percent of Total Billed Charges,48.41% of Total Billed Charges,104.67,100,,3.6,fee Schedule,100% of BCBS fee schedule,104.67,100,,7.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,44.18,47,,49.536,Percent of Total Billed Charges,47% of Total Billed Charges,104.67,100,,7.92,Fee Schedule,100% of BCBS PPO fee schedule,55.23,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,44.18,47,,49.536,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,44.18,47,,49.536,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,85.54,115,,4.512,Fee Schedule,115% of CMS OPPS Rate,85.54,115,,1.88,Fee Schedule,115% of CMS OPPS Rate,44.18,104.67,
RHO (D) TYPING,4011040,CDM,302,RC,86901,HCPCS,Outpatient,,,69.00,69.00,,40.54,58.75,,60.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.54,58.75,,60.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.4,48.41,,81.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.42,100,,3.6,fee Schedule,100% of BCBS fee schedule,30.42,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,32.43,47,,78.96,Percent of Total Billed Charges,47% of Total Billed Charges,30.42,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,40.54,58.75,,60.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.43,47,,78.96,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,32.43,47,,78.96,Percent of Total Billed Charges,47% of Total Billed Charges,2.42,90,,,Fee Schedule,90% of UHC fee schedule,32.43,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,32.43,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.42,40.54,
CA 19-9,4012003,CDM,300,RC,86301,HCPCS,Outpatient,,,42.90,42.90,,25.2,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.2,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.77,48.41,,111.536,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.44,100,,25.2,fee Schedule,100% of BCBS fee schedule,25.44,100,,20.16,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,20.16,47,,108.288,Percent of Total Billed Charges,47% of Total Billed Charges,25.44,100,,20.16,Fee Schedule,100% of BCBS PPO fee schedule,25.2,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.16,47,,108.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,20.16,47,,108.288,Percent of Total Billed Charges,47% of Total Billed Charges,16.86,90,,,Fee Schedule,90% of UHC fee schedule,20.16,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,20.16,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,16.86,25.44,
ALCOHOL (LEGAL),4012006,CDM,301,RC,80320,HCPCS,Outpatient,,,105.00,105.00,,61.69,58.75,,27.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.69,58.75,,27.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.83,48.41,,18.976,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.25,100,,37.224,fee Schedule,100% of BCBS fee schedule,21.25,100,,37.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,49.35,47,,18.424,Percent of Total Billed Charges,47% of Total Billed Charges,21.25,100,,37.44,Fee Schedule,100% of BCBS PPO fee schedule,61.69,58.75,,27.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.35,47,,18.424,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,49.35,47,,18.424,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.35,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,49.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,21.25,61.69,
FECAL LEUKO STAIN,4012007,CDM,306,RC,89055,HCPCS,Outpatient,,,41.00,41.00,,24.09,58.75,,156.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.09,58.75,,156.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.85,48.41,,17.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.23,100,,33.84,fee Schedule,100% of BCBS fee schedule,5.23,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,19.27,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,5.23,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,24.09,58.75,,156.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.27,47,,17.296,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,19.27,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,3.46,90,,,Fee Schedule,90% of UHC fee schedule,19.27,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,19.27,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,3.46,24.09,
CALCULUS ANALYSIS,4012027,CDM,307,RC,82360,HCPCS,Outpatient,,,94.00,94.00,,55.23,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,55.23,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.51,48.41,,25.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.73,100,,99.36,fee Schedule,100% of BCBS fee schedule,15.73,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,44.18,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,15.73,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,55.23,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,44.18,47,,24.816,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,44.18,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,10.42,90,,,Fee Schedule,90% of UHC fee schedule,44.18,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,44.18,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,10.42,55.23,
DNA ANTIBODY,4012043,CDM,302,RC,86225,HCPCS,Outpatient,,,142.00,142.00,,83.43,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,83.43,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,68.74,48.41,,49.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.8,100,,90.72,fee Schedule,100% of BCBS fee schedule,16.8,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,66.74,47,,47.752,Percent of Total Billed Charges,47% of Total Billed Charges,16.8,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,83.43,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,66.74,47,,47.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,66.74,47,,47.752,Percent of Total Billed Charges,47% of Total Billed Charges,11.13,90,,,Fee Schedule,90% of UHC fee schedule,66.74,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,66.74,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,11.13,83.43,
HEAVY MET/SCREEN Q/U,4012053,CDM,301,RC,83015,HCPCS,Outpatient,,,195.00,195.00,,114.56,58.75,,87.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,114.56,58.75,,87.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,94.4,48.41,,29.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,23.03,100,,33.12,fee Schedule,100% of BCBS fee schedule,23.03,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,91.65,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,23.03,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,114.56,58.75,,87.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,91.65,47,,28.2,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,91.65,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,16.97,90,,,Fee Schedule,90% of UHC fee schedule,91.65,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,91.65,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,16.97,114.56,
HLA B-27 CELL TYP,4012062,CDM,302,RC,86812,HCPCS,Outpatient,,,234.00,234.00,,137.48,58.75,,78.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,137.48,58.75,,78.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,113.28,48.41,,14.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,31.54,100,,3.6,fee Schedule,100% of BCBS fee schedule,31.54,100,,25.2,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,109.98,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,31.54,100,,25.2,Fee Schedule,100% of BCBS PPO fee schedule,137.48,58.75,,78.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,109.98,47,,14.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,109.98,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,20.91,90,,,Fee Schedule,90% of UHC fee schedule,109.98,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,109.98,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,20.91,137.48,
PROFILE DRUG QUAL,4012101,CDM,307,RC,80305,HCPCS,Outpatient,,,126.00,126.00,,74.03,58.75,,183.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.03,58.75,,183.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,61,48.41,,60.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.8,100,,56.88,fee Schedule,100% of BCBS fee schedule,13.8,100,,37.224,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,59.22,47,,58.28,Percent of Total Billed Charges,47% of Total Billed Charges,13.8,100,,37.224,Fee Schedule,100% of BCBS PPO fee schedule,74.03,58.75,,183.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,59.22,47,,58.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,59.22,47,,58.28,Percent of Total Billed Charges,47% of Total Billed Charges,10.21,90,,,Fee Schedule,90% of UHC fee schedule,59.22,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,59.22,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,10.21,74.03,
ROTOVIRUS ANTIGES,4012119,CDM,306,RC,86759,HCPCS,Outpatient,,,40.00,40.00,,23.5,58.75,,106.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.5,58.75,,106.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.36,48.41,,29.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.69,100,,68.4,fee Schedule,100% of BCBS fee schedule,18.69,100,,33.84,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,18.8,47,,28.536,Percent of Total Billed Charges,47% of Total Billed Charges,18.69,100,,33.84,Fee Schedule,100% of BCBS PPO fee schedule,23.5,58.75,,106.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,28.536,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.8,47,,28.536,Percent of Total Billed Charges,47% of Total Billed Charges,14.77,90,,,Fee Schedule,90% of UHC fee schedule,18.8,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,14.77,23.5,
G C ANTIBODY,4012152,CDM,306,RC,87591,HCPCS,Outpatient,,,141.00,141.00,,82.84,58.75,,49.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,82.84,58.75,,49.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,68.26,48.41,,63.472,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.89,100,,113.76,fee Schedule,100% of BCBS fee schedule,42.89,100,,99.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,66.27,47,,61.624,Percent of Total Billed Charges,47% of Total Billed Charges,42.89,100,,99.36,Fee Schedule,100% of BCBS PPO fee schedule,82.84,58.75,,49.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,66.27,47,,61.624,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,66.27,47,,61.624,Percent of Total Billed Charges,47% of Total Billed Charges,28.42,90,,,Fee Schedule,90% of UHC fee schedule,66.27,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,66.27,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,28.42,82.84,
RPR-QUAL,4012232,CDM,302,RC,86592,HCPCS,Outpatient,,,50.60,50.60,,29.73,58.75,,111.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.73,58.75,,111.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.5,48.41,,22.504,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.23,100,,5.76,fee Schedule,100% of BCBS fee schedule,5.23,100,,90.72,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,23.78,47,,21.848,Percent of Total Billed Charges,47% of Total Billed Charges,5.23,100,,90.72,Fee Schedule,100% of BCBS PPO fee schedule,29.73,58.75,,111.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.78,47,,21.848,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.78,47,,21.848,Percent of Total Billed Charges,47% of Total Billed Charges,3.46,90,,,Fee Schedule,90% of UHC fee schedule,23.78,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,23.78,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,3.46,29.73,
TEGRETOL LEVEL,4012344,CDM,301,RC,80156,HCPCS,Outpatient,,,137.50,137.50,,80.78,58.75,,76.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,80.78,58.75,,76.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.56,48.41,,54.104,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.8,100,,3.6,fee Schedule,100% of BCBS fee schedule,17.8,100,,33.12,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,64.63,47,,52.528,Percent of Total Billed Charges,47% of Total Billed Charges,17.8,100,,33.12,Fee Schedule,100% of BCBS PPO fee schedule,80.78,58.75,,76.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,64.63,47,,52.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,64.63,47,,52.528,Percent of Total Billed Charges,47% of Total Billed Charges,11.8,90,,,Fee Schedule,90% of UHC fee schedule,64.63,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,64.63,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,11.8,80.78,
CLONAZAPAM,4012376,CDM,301,RC,80346,HCPCS,Outpatient,,,53.25,53.25,,31.28,58.75,,52.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.28,58.75,,52.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.78,48.41,,15.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.37,100,,3.6,fee Schedule,100% of BCBS fee schedule,42.37,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,25.03,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,42.37,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,31.28,58.75,,52.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,25.03,47,,15.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,25.03,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,25.03,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,25.03,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,25.03,42.37,
CRP,4012384,CDM,300,RC,86140,HCPCS,Outpatient,,,86.90,86.90,,51.05,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.05,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.07,48.41,,30.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.33,100,,3.96,fee Schedule,100% of BCBS fee schedule,6.33,100,,56.88,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,40.84,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,6.33,100,,56.88,Fee Schedule,100% of BCBS PPO fee schedule,51.05,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.84,47,,29.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.84,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,4.19,90,,,Fee Schedule,90% of UHC fee schedule,40.84,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,40.84,47,,19.44,Percent of Total Billed Charges,47% of Total Billed Charges,4.19,51.05,
DIAZEPAM VALIUM,4012438,CDM,301,RC,80346,HCPCS,Outpatient,,,156.00,156.00,,91.65,58.75,,116.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,91.65,58.75,,116.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.52,48.41,,36.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.37,100,,3.6,fee Schedule,100% of BCBS fee schedule,42.37,100,,68.4,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,73.32,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,42.37,100,,68.4,Fee Schedule,100% of BCBS PPO fee schedule,91.65,58.75,,116.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,73.32,47,,35.344,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,73.32,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,73.32,47,,19.44,Percent of Total Billed Charges,47% of Total Billed Charges,73.32,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,42.37,91.65,
RUBELLA,4012478,CDM,302,RC,86762,HCPCS,Outpatient,,,27.00,27.00,,15.86,58.75,,32.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.86,58.75,,32.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.07,48.41,,32.8,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.59,100,,15.84,fee Schedule,100% of BCBS fee schedule,17.59,100,,113.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,12.69,47,,31.848,Percent of Total Billed Charges,47% of Total Billed Charges,17.59,100,,113.76,Fee Schedule,100% of BCBS PPO fee schedule,15.86,58.75,,32.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,31.848,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.69,47,,31.848,Percent of Total Billed Charges,47% of Total Billed Charges,11.66,90,,,Fee Schedule,90% of UHC fee schedule,12.69,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,47,,51.888,Percent of Total Billed Charges,47% of Total Billed Charges,11.66,17.59,
HGB AIC,4012495,CDM,301,RC,83036,HCPCS,Outpatient,,,128.85,128.85,,75.7,58.75,,24.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.7,58.75,,24.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.38,48.41,,46.472,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.87,100,,8.64,fee Schedule,100% of BCBS fee schedule,11.87,100,,5.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,60.56,47,,45.12,Percent of Total Billed Charges,47% of Total Billed Charges,11.87,100,,5.76,Fee Schedule,100% of BCBS PPO fee schedule,75.7,58.75,,24.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,60.56,47,,45.12,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,60.56,47,,45.12,Percent of Total Billed Charges,47% of Total Billed Charges,7.87,90,,,Fee Schedule,90% of UHC fee schedule,60.56,47,,51.888,Percent of Total Billed Charges,47% of Total Billed Charges,60.56,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,7.87,75.7,
HEMOGL ELECTROPHORES,4012507,CDM,305,RC,83020,HCPCS,Outpatient,,,130.00,130.00,,76.38,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.38,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.93,48.41,,27.112,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.73,100,,3.6,fee Schedule,100% of BCBS fee schedule,15.73,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,61.1,47,,26.32,Percent of Total Billed Charges,47% of Total Billed Charges,15.73,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,76.38,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,61.1,47,,26.32,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,61.1,47,,26.32,Percent of Total Billed Charges,47% of Total Billed Charges,10.42,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.42,76.38,
CYCLOSPORINE,4012549,CDM,300,RC,80158,HCPCS,Outpatient,,,58.30,58.30,,34.25,58.75,,23.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.25,58.75,,23.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.22,48.41,,72.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.07,100,,3.6,fee Schedule,100% of BCBS fee schedule,22.07,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,27.4,47,,69.936,Percent of Total Billed Charges,47% of Total Billed Charges,22.07,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,34.25,58.75,,23.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.4,47,,69.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,27.4,47,,69.936,Percent of Total Billed Charges,47% of Total Billed Charges,14.63,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14.63,34.25,
PARATH HORMONE PTH,4012607,CDM,301,RC,83970,HCPCS,Outpatient,,,333.00,333.00,,195.64,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,195.64,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,161.21,48.41,,15.76,Percent of Total Billed Charges,48.41% of Total Billed Charges,50.45,100,,3.6,fee Schedule,100% of BCBS fee schedule,50.45,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,156.51,47,,15.304,Percent of Total Billed Charges,47% of Total Billed Charges,50.45,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,195.64,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,156.51,47,,15.304,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,156.51,47,,15.304,Percent of Total Billed Charges,47% of Total Billed Charges,33.44,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,33.44,195.64,
OXCARBAZEPINE,4012627,CDM,301,RC,80183,HCPCS,Outpatient,,,71.00,71.00,,41.71,58.75,,29.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.71,58.75,,29.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.37,48.41,,46.864,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.2,100,,3.6,fee Schedule,100% of BCBS fee schedule,16.2,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,33.37,47,,45.496,Percent of Total Billed Charges,47% of Total Billed Charges,16.2,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,41.71,58.75,,29.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.37,47,,45.496,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,33.37,47,,45.496,Percent of Total Billed Charges,47% of Total Billed Charges,10.74,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.74,41.71,
PLATELET TRANSFUSE,4012636,CDM,390,RC,,,Outpatient,,,71.00,71.00,,41.71,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.71,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.37,48.41,,24.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,63.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,63.9,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,33.37,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,63.9,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,41.71,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.37,47,,24.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,33.37,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,350,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,33.37,350,
HEPATIC FUNCT PANEL,4012658,CDM,301,RC,80076,HCPCS,Outpatient,,,186.00,186.00,,109.28,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,109.28,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,90.04,48.41,,118.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.99,100,,13.68,fee Schedule,100% of BCBS fee schedule,9.99,100,,8.64,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,87.42,47,,115.112,Percent of Total Billed Charges,47% of Total Billed Charges,9.99,100,,8.64,Fee Schedule,100% of BCBS PPO fee schedule,109.28,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,87.42,47,,115.112,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,87.42,47,,115.112,Percent of Total Billed Charges,47% of Total Billed Charges,6.62,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.62,109.28,
TROPONIN,4012660,CDM,301,RC,84484,HCPCS,Outpatient,,,166.40,166.40,,97.76,58.75,,68.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,97.76,58.75,,68.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,80.55,48.41,,56.696,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.78,100,,95.04,fee Schedule,100% of BCBS fee schedule,12.78,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,78.21,47,,55.048,Percent of Total Billed Charges,47% of Total Billed Charges,12.78,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,97.76,58.75,,68.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,78.21,47,,55.048,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,78.21,47,,55.048,Percent of Total Billed Charges,47% of Total Billed Charges,10.1,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.1,97.76,
BNP,4012680,CDM,301,RC,83880,HCPCS,Outpatient,,,391.00,391.00,,229.71,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,229.71,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,189.28,48.41,,43.76,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.95,100,,8.712,fee Schedule,100% of BCBS fee schedule,42.95,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,183.77,47,,42.488,Percent of Total Billed Charges,47% of Total Billed Charges,42.95,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,229.71,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,183.77,47,,42.488,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,183.77,47,,42.488,Percent of Total Billed Charges,47% of Total Billed Charges,31.8,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31.8,229.71,
SEROTONIN BLOOD,4012686,CDM,301,RC,84260,HCPCS,Outpatient,,,227.00,227.00,,133.36,58.75,,24.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,133.36,58.75,,24.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,109.89,48.41,,33.272,Percent of Total Billed Charges,48.41% of Total Billed Charges,37.87,100,,7.92,fee Schedule,100% of BCBS fee schedule,37.87,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,106.69,47,,32.304,Percent of Total Billed Charges,47% of Total Billed Charges,37.87,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,133.36,58.75,,24.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,106.69,47,,32.304,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,106.69,47,,32.304,Percent of Total Billed Charges,47% of Total Billed Charges,25.09,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25.09,133.36,
T-4 THYROXINE,4012697,CDM,301,RC,84436,HCPCS,Outpatient,,,105.60,105.60,,62.04,58.75,,55.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.04,58.75,,55.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.12,48.41,,51.896,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.39,100,,3.6,fee Schedule,100% of BCBS fee schedule,8.39,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,49.63,47,,50.384,Percent of Total Billed Charges,47% of Total Billed Charges,8.39,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,62.04,58.75,,55.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.63,47,,50.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,49.63,47,,50.384,Percent of Total Billed Charges,47% of Total Billed Charges,5.56,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.56,62.04,
TESTOSTERONE-SERUM,4012700,CDM,301,RC,84403,HCPCS,Outpatient,,,237.00,237.00,,139.24,58.75,,70.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,139.24,58.75,,70.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,114.73,48.41,,55.672,Percent of Total Billed Charges,48.41% of Total Billed Charges,31.55,100,,3.6,fee Schedule,100% of BCBS fee schedule,31.55,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,111.39,47,,54.048,Percent of Total Billed Charges,47% of Total Billed Charges,31.55,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,139.24,58.75,,70.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,111.39,47,,54.048,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,111.39,47,,54.048,Percent of Total Billed Charges,47% of Total Billed Charges,20.91,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20.91,139.24,
THYROID HORMONETSH,4012711,CDM,301,RC,84443,HCPCS,Outpatient,,,163.75,163.75,,96.2,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.2,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.27,48.41,,22.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.54,100,,87.12,fee Schedule,100% of BCBS fee schedule,20.54,100,,13.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,76.96,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,20.54,100,,13.68,Fee Schedule,100% of BCBS PPO fee schedule,96.2,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,76.96,47,,21.432,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,76.96,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,13.61,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.61,96.2,
COLONY COUNT-CULTURE,4012811,CDM,306,RC,87086,HCPCS,Outpatient,,,112.75,112.75,,66.24,58.75,,24.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.24,58.75,,24.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,54.58,48.41,,70.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.87,100,,3.6,fee Schedule,100% of BCBS fee schedule,9.87,100,,95.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,52.99,47,,68.056,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,100,,95.04,Fee Schedule,100% of BCBS PPO fee schedule,66.24,58.75,,24.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,52.99,47,,68.056,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,52.99,47,,68.056,Percent of Total Billed Charges,47% of Total Billed Charges,6.53,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.53,66.24,
ACETONE-SERUM,4012854,CDM,301,RC,82009,HCPCS,Outpatient,,,44.00,44.00,,25.85,58.75,,26.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.85,58.75,,26.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.3,48.41,,65.448,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.52,100,,10.08,fee Schedule,100% of BCBS fee schedule,5.52,100,,8.712,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,20.68,47,,63.544,Percent of Total Billed Charges,47% of Total Billed Charges,5.52,100,,8.712,Fee Schedule,100% of BCBS PPO fee schedule,25.85,58.75,,26.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,63.544,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,20.68,47,,63.544,Percent of Total Billed Charges,47% of Total Billed Charges,3.66,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.66,25.85,
SJOGRENS SSA-SSB,4012974,CDM,302,RC,86235,HCPCS,Outpatient,,,247.80,247.80,,145.58,58.75,,41.832,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.58,58.75,,41.832,Percent of Total Billed Charges,58.75% of Total Billed Charges,119.96,48.41,,76.856,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.92,100,,3.6,fee Schedule,100% of BCBS fee schedule,21.92,100,,7.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,116.47,47,,74.616,Percent of Total Billed Charges,47% of Total Billed Charges,21.92,100,,7.92,Fee Schedule,100% of BCBS PPO fee schedule,145.58,58.75,,41.832,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,116.47,47,,74.616,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,116.47,47,,74.616,Percent of Total Billed Charges,47% of Total Billed Charges,14.53,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14.53,145.58,
ANTI NUCLEAR ABDY,4014004,CDM,302,RC,86038,HCPCS,Outpatient,,,70.00,70.00,,41.13,58.75,,54.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.13,58.75,,54.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.89,48.41,,40.896,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.77,100,,3.6,fee Schedule,100% of BCBS fee schedule,14.77,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,32.9,47,,39.704,Percent of Total Billed Charges,47% of Total Billed Charges,14.77,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,41.13,58.75,,54.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.9,47,,39.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,32.9,47,,39.704,Percent of Total Billed Charges,47% of Total Billed Charges,9.79,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9.79,41.13,
C DIFFICILE,4014017,CDM,306,RC,87324,HCPCS,Outpatient,,,52.80,52.80,,31.02,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.02,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.56,48.41,,49.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.65,100,,3.96,fee Schedule,100% of BCBS fee schedule,14.65,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,24.82,47,,48.128,Percent of Total Billed Charges,47% of Total Billed Charges,14.65,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,31.02,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.82,47,,48.128,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,24.82,47,,48.128,Percent of Total Billed Charges,47% of Total Billed Charges,9.7,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9.7,31.02,
COMPLIMENT C4,4014025,CDM,302,RC,86160,HCPCS,Outpatient,,,32.00,32.00,,18.8,58.75,,52.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,52.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,78.232,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.66,100,,5.76,fee Schedule,100% of BCBS fee schedule,14.66,100,,87.12,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,15.04,47,,75.952,Percent of Total Billed Charges,47% of Total Billed Charges,14.66,100,,87.12,Fee Schedule,100% of BCBS PPO fee schedule,18.8,58.75,,52.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,75.952,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,75.952,Percent of Total Billed Charges,47% of Total Billed Charges,9.72,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9.72,18.8,
GIARDIA,4014026,CDM,306,RC,87329,HCPCS,Outpatient,,,49.00,49.00,,28.79,58.75,,18.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.79,58.75,,18.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.72,48.41,,69.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.65,100,,3.6,fee Schedule,100% of BCBS fee schedule,14.65,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,23.03,47,,67.68,Percent of Total Billed Charges,47% of Total Billed Charges,14.65,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,28.79,58.75,,18.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.03,47,,67.68,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.03,47,,67.68,Percent of Total Billed Charges,47% of Total Billed Charges,9.7,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9.7,28.79,
HCG SLIDE,4014042,CDM,300,RC,84703,HCPCS,Outpatient,,,61.00,61.00,,35.84,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.84,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.53,48.41,,32.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.2,100,,3.6,fee Schedule,100% of BCBS fee schedule,9.2,100,,10.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,28.67,47,,31.4,Percent of Total Billed Charges,47% of Total Billed Charges,9.2,100,,10.08,Fee Schedule,100% of BCBS PPO fee schedule,35.84,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,31.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.67,47,,31.4,Percent of Total Billed Charges,47% of Total Billed Charges,6.09,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.09,35.84,
MONO TEST,4014047,CDM,302,RC,86663,HCPCS,Outpatient,,,62.70,62.70,,36.84,58.75,,66.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.84,58.75,,66.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.35,48.41,,58.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.04,100,,3.6,fee Schedule,100% of BCBS fee schedule,16.04,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,29.47,47,,56.568,Percent of Total Billed Charges,47% of Total Billed Charges,16.04,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,36.84,58.75,,66.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.47,47,,56.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,29.47,47,,56.568,Percent of Total Billed Charges,47% of Total Billed Charges,10.63,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.63,36.84,
RHEUMATOID FACT/QUAL,4014053,CDM,302,RC,86430,HCPCS,Outpatient,,,64.00,64.00,,37.6,58.75,,72.848,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.6,58.75,,72.848,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.98,48.41,,37.176,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.93,100,,3.6,fee Schedule,100% of BCBS fee schedule,6.93,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,30.08,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,6.93,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,37.6,58.75,,72.848,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.08,47,,36.096,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,30.08,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,4.98,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.98,37.6,
SMITH/ RNP AB,4014058,CDM,302,RC,86235,HCPCS,Outpatient,,,44.00,44.00,,25.85,58.75,,56.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.85,58.75,,56.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.3,48.41,,13.168,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.92,100,,5.04,fee Schedule,100% of BCBS fee schedule,21.92,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,20.68,47,,12.784,Percent of Total Billed Charges,47% of Total Billed Charges,21.92,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,25.85,58.75,,56.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,12.784,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,20.68,47,,12.784,Percent of Total Billed Charges,47% of Total Billed Charges,14.53,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14.53,25.85,
CELL CNT-SYNOVIAL W/CRYSTALS,4015008,CDM,305,RC,89051,HCPCS,Outpatient,,,146.70,146.70,,86.19,58.75,,61.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.19,58.75,,61.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,71.02,48.41,,40.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.73,100,,5.04,fee Schedule,100% of BCBS fee schedule,6.73,100,,5.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,68.95,47,,39.648,Percent of Total Billed Charges,47% of Total Billed Charges,6.73,100,,5.76,Fee Schedule,100% of BCBS PPO fee schedule,86.19,58.75,,61.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,68.95,47,,39.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,68.95,47,,39.648,Percent of Total Billed Charges,47% of Total Billed Charges,4.54,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.54,86.19,
HEMATOCRIT,4015042,CDM,305,RC,85014,HCPCS,Outpatient,,,66.00,66.00,,38.78,58.75,,98.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.78,58.75,,98.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.95,48.41,,37.12,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.89,100,,7.2,fee Schedule,100% of BCBS fee schedule,2.89,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,31.02,47,,36.04,Percent of Total Billed Charges,47% of Total Billed Charges,2.89,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,38.78,58.75,,98.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.02,47,,36.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.02,47,,36.04,Percent of Total Billed Charges,47% of Total Billed Charges,1.92,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.92,38.78,
PLATELET COUNT,4015055,CDM,305,RC,85049,HCPCS,Outpatient,,,52.80,52.80,,31.02,58.75,,135.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.02,58.75,,135.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.56,48.41,,52.28,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.47,100,,13.68,fee Schedule,100% of BCBS fee schedule,5.47,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,24.82,47,,50.76,Percent of Total Billed Charges,47% of Total Billed Charges,5.47,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,31.02,58.75,,135.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.82,47,,50.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,24.82,47,,50.76,Percent of Total Billed Charges,47% of Total Billed Charges,3.63,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.63,31.02,
COMPLETE BLOOD COUNT (CBC),4015061,CDM,305,RC,85025,HCPCS,Outpatient,,,118.60,118.60,,69.68,58.75,,23.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.68,58.75,,23.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.41,48.41,,72.168,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.49,100,,7.92,fee Schedule,100% of BCBS fee schedule,9.49,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,55.74,47,,70.064,Percent of Total Billed Charges,47% of Total Billed Charges,9.49,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,69.68,58.75,,23.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.74,47,,70.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,55.74,47,,70.064,Percent of Total Billed Charges,47% of Total Billed Charges,6.29,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.29,69.68,
PROTHROMBIN TIME PT,4015067,CDM,300,RC,85610,HCPCS,Outpatient,,,149.70,149.70,,87.95,58.75,,21.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,87.95,58.75,,21.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,72.47,48.41,,30.248,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.81,100,,8.64,fee Schedule,100% of BCBS fee schedule,4.81,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,70.36,47,,29.368,Percent of Total Billed Charges,47% of Total Billed Charges,4.81,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,87.95,58.75,,21.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,70.36,47,,29.368,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,70.36,47,,29.368,Percent of Total Billed Charges,47% of Total Billed Charges,3.47,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.47,87.95,
RED BLOOD CELL RBC,4015071,CDM,305,RC,85041,HCPCS,Outpatient,,,28.00,28.00,,16.45,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,38.768,Percent of Total Billed Charges,48.41% of Total Billed Charges,3.69,100,,3.96,fee Schedule,100% of BCBS fee schedule,3.69,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,13.16,47,,37.64,Percent of Total Billed Charges,47% of Total Billed Charges,3.69,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,16.45,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,37.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,37.64,Percent of Total Billed Charges,47% of Total Billed Charges,2.45,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.45,16.45,
RETICUL COUNT,4015074,CDM,305,RC,85045,HCPCS,Outpatient,,,51.70,51.70,,30.37,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.37,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.03,48.41,,58.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.88,100,,3.96,fee Schedule,100% of BCBS fee schedule,4.88,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,24.3,47,,56.4,Percent of Total Billed Charges,47% of Total Billed Charges,4.88,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,30.37,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.3,47,,56.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,24.3,47,,56.4,Percent of Total Billed Charges,47% of Total Billed Charges,3.23,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.23,30.37,
SEDIMENTATION RATE 1,4015076,CDM,300,RC,85651,HCPCS,Outpatient,,,55.65,55.65,,32.69,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.69,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,26.94,48.41,,36.288,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.49,100,,3.6,fee Schedule,100% of BCBS fee schedule,4.49,100,,7.2,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,26.16,47,,35.232,Percent of Total Billed Charges,47% of Total Billed Charges,4.49,100,,7.2,Fee Schedule,100% of BCBS PPO fee schedule,32.69,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.16,47,,35.232,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.16,47,,35.232,Percent of Total Billed Charges,47% of Total Billed Charges,3.46,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.46,32.69,
SEMEN ANAL/POSTVASC,4015079,CDM,309,RC,89300,HCPCS,Outpatient,,,89.00,89.00,,52.29,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,52.29,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,43.08,48.41,,36.792,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.91,100,,5.76,fee Schedule,100% of BCBS fee schedule,10.91,100,,13.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,41.83,47,,35.72,Percent of Total Billed Charges,47% of Total Billed Charges,10.91,100,,13.68,Fee Schedule,100% of BCBS PPO fee schedule,52.29,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,41.83,47,,35.72,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,41.83,47,,35.72,Percent of Total Billed Charges,47% of Total Billed Charges,7.97,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.97,52.29,
CULTURE (ANY SOURCE),4015086,CDM,306,RC,87070,HCPCS,Outpatient,,,117.00,117.00,,68.74,58.75,,72.848,Percent of Total Billed Charges,58.75% of Total Billed Charges,68.74,58.75,,72.848,Percent of Total Billed Charges,58.75% of Total Billed Charges,56.64,48.41,,44.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.53,100,,3.6,fee Schedule,100% of BCBS fee schedule,10.53,100,,7.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,54.99,47,,42.864,Percent of Total Billed Charges,47% of Total Billed Charges,10.53,100,,7.92,Fee Schedule,100% of BCBS PPO fee schedule,68.74,58.75,,72.848,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,54.99,47,,42.864,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,54.99,47,,42.864,Percent of Total Billed Charges,47% of Total Billed Charges,6.98,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.98,68.74,
HEMOGL SICKE SOLUB,4015089,CDM,305,RC,85660,HCPCS,Outpatient,,,51.00,51.00,,29.96,58.75,,35.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.96,58.75,,35.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.69,48.41,,20.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.73,100,,3.6,fee Schedule,100% of BCBS fee schedule,6.73,100,,8.64,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,23.97,47,,20.024,Percent of Total Billed Charges,47% of Total Billed Charges,6.73,100,,8.64,Fee Schedule,100% of BCBS PPO fee schedule,29.96,58.75,,35.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,20.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.97,47,,20.024,Percent of Total Billed Charges,47% of Total Billed Charges,4.46,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.46,29.96,
PTT,4015091,CDM,300,RC,85730,HCPCS,Outpatient,,,112.00,112.00,,65.8,58.75,,77.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,65.8,58.75,,77.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,54.22,48.41,,61.576,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.34,100,,5.04,fee Schedule,100% of BCBS fee schedule,7.34,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,52.64,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,7.34,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,65.8,58.75,,77.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,52.64,47,,59.784,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,52.64,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,4.87,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.87,65.8,
WBC,4015093,CDM,305,RC,85048,HCPCS,Outpatient,,,39.00,39.00,,22.91,58.75,,27.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.91,58.75,,27.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.88,48.41,,83.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,3.1,100,,10.8,fee Schedule,100% of BCBS fee schedule,3.1,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,18.33,47,,80.84,Percent of Total Billed Charges,47% of Total Billed Charges,3.1,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,22.91,58.75,,27.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.33,47,,80.84,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.33,47,,80.84,Percent of Total Billed Charges,47% of Total Billed Charges,2.06,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.06,22.91,
HEMOGLOBIN,4015095,CDM,305,RC,85018,HCPCS,Outpatient,,,66.00,66.00,,38.78,58.75,,65.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.78,58.75,,65.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.95,48.41,,30.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.89,100,,1.44,fee Schedule,100% of BCBS fee schedule,2.89,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,31.02,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,2.89,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,38.78,58.75,,65.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.02,47,,29.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.02,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,1.92,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.92,38.78,
CULTURE ACID FAST,4016003,CDM,306,RC,87116,HCPCS,Outpatient,,,141.00,141.00,,82.84,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,82.84,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,68.26,48.41,,54.608,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.2,100,,3.6,fee Schedule,100% of BCBS fee schedule,13.2,100,,5.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,66.27,47,,53.016,Percent of Total Billed Charges,47% of Total Billed Charges,13.2,100,,5.76,Fee Schedule,100% of BCBS PPO fee schedule,82.84,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,66.27,47,,53.016,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,66.27,47,,53.016,Percent of Total Billed Charges,47% of Total Billed Charges,8.75,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.75,82.84,
CULTURE SPUTUM,4016005,CDM,306,RC,87075,HCPCS,Outpatient,,,155.00,155.00,,91.06,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,91.06,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.04,48.41,,53.056,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.57,100,,4.32,fee Schedule,100% of BCBS fee schedule,11.57,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,72.85,47,,51.512,Percent of Total Billed Charges,47% of Total Billed Charges,11.57,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,91.06,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,72.85,47,,51.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,72.85,47,,51.512,Percent of Total Billed Charges,47% of Total Billed Charges,7.67,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.67,91.06,
RAPID STREP SCREEN,4016008,CDM,302,RC,87430,HCPCS,Outpatient,,,121.00,121.00,,71.09,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,71.09,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.58,48.41,,78.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.23,100,,9.36,fee Schedule,100% of BCBS fee schedule,17.23,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,56.87,47,,76.328,Percent of Total Billed Charges,47% of Total Billed Charges,17.23,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,71.09,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,56.87,47,,76.328,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,56.87,47,,76.328,Percent of Total Billed Charges,47% of Total Billed Charges,13.62,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.62,71.09,
CULTURE BLOOD,4016009,CDM,306,RC,87040,HCPCS,Outpatient,,,131.75,131.75,,77.4,58.75,,39.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,77.4,58.75,,39.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,63.78,48.41,,164.824,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.62,100,,4.32,fee Schedule,100% of BCBS fee schedule,12.62,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,61.92,47,,160.024,Percent of Total Billed Charges,47% of Total Billed Charges,12.62,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,77.4,58.75,,39.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,61.92,47,,160.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,61.92,47,,160.024,Percent of Total Billed Charges,47% of Total Billed Charges,8.36,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.36,77.4,
CULTURE FUNGUS,4016015,CDM,306,RC,87106,HCPCS,Outpatient,,,210.00,210.00,,123.38,58.75,,56.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,123.38,58.75,,56.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,101.66,48.41,,83.92,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.62,100,,19.44,fee Schedule,100% of BCBS fee schedule,12.62,100,,10.8,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,98.7,47,,81.48,Percent of Total Billed Charges,47% of Total Billed Charges,12.62,100,,10.8,Fee Schedule,100% of BCBS PPO fee schedule,123.38,58.75,,56.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,98.7,47,,81.48,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,98.7,47,,81.48,Percent of Total Billed Charges,47% of Total Billed Charges,8.36,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.36,123.38,
STOOL CULTURE,4016017,CDM,306,RC,87045,HCPCS,Outpatient,,,288.00,288.00,,169.2,58.75,,32.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,169.2,58.75,,32.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,139.42,48.41,,64.672,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.54,100,,3.6,fee Schedule,100% of BCBS fee schedule,11.54,100,,1.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,135.36,47,,62.792,Percent of Total Billed Charges,47% of Total Billed Charges,11.54,100,,1.44,Fee Schedule,100% of BCBS PPO fee schedule,169.2,58.75,,32.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,135.36,47,,62.792,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,135.36,47,,62.792,Percent of Total Billed Charges,47% of Total Billed Charges,7.65,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.65,169.2,
OCCULT BL FECES1-3,4016040,CDM,306,RC,82270,HCPCS,Outpatient,,,49.00,49.00,,28.79,58.75,,87.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.79,58.75,,87.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.72,48.41,,135.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.49,100,,15.84,fee Schedule,100% of BCBS fee schedule,4.49,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,23.03,47,,131.6,Percent of Total Billed Charges,47% of Total Billed Charges,4.49,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,28.79,58.75,,87.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.03,47,,131.6,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.03,47,,131.6,Percent of Total Billed Charges,47% of Total Billed Charges,3.55,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.55,28.79,
WET MOUNT SMEAR,4016043,CDM,306,RC,87210,HCPCS,Outpatient,,,46.00,46.00,,27.03,58.75,,19.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.03,58.75,,19.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.27,48.41,,58.576,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.97,100,,4.32,fee Schedule,100% of BCBS fee schedule,5.97,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,21.62,47,,56.872,Percent of Total Billed Charges,47% of Total Billed Charges,5.97,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,27.03,58.75,,19.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.62,47,,56.872,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,21.62,47,,56.872,Percent of Total Billed Charges,47% of Total Billed Charges,4.72,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.72,27.03,
OVA & PARASITIES CO,4016044,CDM,306,RC,87177,HCPCS,Outpatient,,,66.00,66.00,,38.78,58.75,,56.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.78,58.75,,56.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.95,48.41,,41.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.88,100,,3.6,fee Schedule,100% of BCBS fee schedule,10.88,100,,9.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,31.02,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,10.88,100,,9.36,Fee Schedule,100% of BCBS PPO fee schedule,38.78,58.75,,56.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.02,47,,39.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.02,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,7.21,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.21,38.78,
SENSITV/DIS PERORG,4016047,CDM,306,RC,87184,HCPCS,Outpatient,,,127.00,127.00,,74.61,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.61,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.48,48.41,,18.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.43,100,,3.6,fee Schedule,100% of BCBS fee schedule,8.43,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,59.69,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,8.43,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,74.61,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,59.69,47,,17.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,59.69,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,6.06,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.06,74.61,
SMEAR FUNGUS WET PRE,4016053,CDM,306,RC,87220,HCPCS,Outpatient,,,75.00,75.00,,44.06,58.75,,143.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.06,58.75,,143.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.31,48.41,,30.208,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.23,100,,1.44,fee Schedule,100% of BCBS fee schedule,5.23,100,,19.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,35.25,47,,29.328,Percent of Total Billed Charges,47% of Total Billed Charges,5.23,100,,19.44,Fee Schedule,100% of BCBS PPO fee schedule,44.06,58.75,,143.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.25,47,,29.328,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,35.25,47,,29.328,Percent of Total Billed Charges,47% of Total Billed Charges,3.46,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.46,44.06,
GRAM STAIN,4016054,CDM,306,RC,87205,HCPCS,Outpatient,,,38.00,38.00,,22.33,58.75,,68.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.33,58.75,,68.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.4,48.41,,24.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.23,100,,10.08,fee Schedule,100% of BCBS fee schedule,5.23,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,17.86,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,5.23,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,22.33,58.75,,68.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,24.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.86,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,3.46,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.46,22.33,
CULTURE URINE,4016069,CDM,306,RC,87086,HCPCS,Outpatient,,,155.00,155.00,,91.06,58.75,,53.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,91.06,58.75,,53.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.04,48.41,,62.896,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.87,100,,5.76,fee Schedule,100% of BCBS fee schedule,9.87,100,,15.84,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,72.85,47,,61.064,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,100,,15.84,Fee Schedule,100% of BCBS PPO fee schedule,91.06,58.75,,53.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,72.85,47,,61.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,72.85,47,,61.064,Percent of Total Billed Charges,47% of Total Billed Charges,6.53,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.53,91.06,
U/A ROUTINE COMPLETE,4017011,CDM,307,RC,81001,HCPCS,Outpatient,,,75.90,75.90,,44.59,58.75,,40.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.59,58.75,,40.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.74,48.41,,36.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,3.87,100,,27.36,fee Schedule,100% of BCBS fee schedule,3.87,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,35.67,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,3.87,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,44.59,58.75,,40.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.67,47,,35.344,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,35.67,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,2.57,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.57,44.59,
ACETAMINOPHEN,4018001,CDM,301,RC,80329,HCPCS,Outpatient,,,163.90,163.90,,96.29,58.75,,62.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.29,58.75,,62.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.34,48.41,,48.8,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.19,100,,3.96,fee Schedule,100% of BCBS fee schedule,15.19,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,77.03,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,15.19,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,96.29,58.75,,62.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.03,47,,47.376,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,77.03,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15.19,96.29,
ALBUMIN SERUM,4018008,CDM,301,RC,82040,HCPCS,Outpatient,,,58.10,58.10,,34.13,58.75,,67.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.13,58.75,,67.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.13,48.41,,27.496,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.05,100,,4.32,fee Schedule,100% of BCBS fee schedule,6.05,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,27.31,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,6.05,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,34.13,58.75,,67.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.31,47,,26.696,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,27.31,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,4.01,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.01,34.13,
ALCOHOL,4018011,CDM,301,RC,80320,HCPCS,Outpatient,,,139.70,139.70,,82.07,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,82.07,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,67.63,48.41,,26.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.25,100,,3.6,fee Schedule,100% of BCBS fee schedule,21.25,100,,1.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,65.66,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,21.25,100,,1.44,Fee Schedule,100% of BCBS PPO fee schedule,82.07,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,65.66,47,,25.944,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,65.66,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21.25,82.07,
AMMONIA,4018022,CDM,301,RC,82140,HCPCS,Outpatient,,,40.00,40.00,,23.5,58.75,,85.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.5,58.75,,85.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.36,48.41,,49.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.81,100,,5.04,fee Schedule,100% of BCBS fee schedule,17.81,100,,10.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,18.8,47,,48.128,Percent of Total Billed Charges,47% of Total Billed Charges,17.81,100,,10.08,Fee Schedule,100% of BCBS PPO fee schedule,23.5,58.75,,85.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,48.128,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.8,47,,48.128,Percent of Total Billed Charges,47% of Total Billed Charges,11.8,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.8,23.5,
AMYLASE,4018027,CDM,301,RC,82150,HCPCS,Outpatient,,,79.00,79.00,,46.41,58.75,,79.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.41,58.75,,79.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.24,48.41,,34.08,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.92,100,,3.6,fee Schedule,100% of BCBS fee schedule,7.92,100,,5.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,37.13,47,,33.088,Percent of Total Billed Charges,47% of Total Billed Charges,7.92,100,,5.76,Fee Schedule,100% of BCBS PPO fee schedule,46.41,58.75,,79.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.13,47,,33.088,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,37.13,47,,33.088,Percent of Total Billed Charges,47% of Total Billed Charges,5.25,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.25,46.41,
BILIRUBIN DIRECT,4018054,CDM,301,RC,82248,HCPCS,Outpatient,,,94.00,94.00,,55.23,58.75,,93.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,55.23,58.75,,93.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.51,48.41,,51.544,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.13,100,,3.6,fee Schedule,100% of BCBS fee schedule,6.13,100,,27.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,44.18,47,,50.048,Percent of Total Billed Charges,47% of Total Billed Charges,6.13,100,,27.36,Fee Schedule,100% of BCBS PPO fee schedule,55.23,58.75,,93.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,44.18,47,,50.048,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,44.18,47,,50.048,Percent of Total Billed Charges,47% of Total Billed Charges,4.07,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.07,55.23,
BILIRUBIN TOTAL,4018056,CDM,301,RC,82247,HCPCS,Outpatient,,,84.70,84.70,,49.76,58.75,,49.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.76,58.75,,49.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,41,48.41,,26.704,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.13,100,,5.04,fee Schedule,100% of BCBS fee schedule,6.13,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,39.81,47,,25.928,Percent of Total Billed Charges,47% of Total Billed Charges,6.13,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,49.76,58.75,,49.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,39.81,47,,25.928,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,39.81,47,,25.928,Percent of Total Billed Charges,47% of Total Billed Charges,4.07,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.07,49.76,
CALCIUM,4018074,CDM,301,RC,82310,HCPCS,Outpatient,,,120.00,120.00,,70.5,58.75,,60.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,70.5,58.75,,60.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.09,48.41,,73.192,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,100,,9.36,fee Schedule,100% of BCBS fee schedule,6.3,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,56.4,47,,71.064,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,70.5,58.75,,60.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,56.4,47,,71.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,56.4,47,,71.064,Percent of Total Billed Charges,47% of Total Billed Charges,4.18,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.18,70.5,
CARBON DIOXIDE,4018081,CDM,300,RC,82374,HCPCS,Outpatient,,,70.00,70.00,,41.13,58.75,,94.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.13,58.75,,94.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.89,48.41,,58.768,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.97,100,,18,fee Schedule,100% of BCBS fee schedule,5.97,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,32.9,47,,57.056,Percent of Total Billed Charges,47% of Total Billed Charges,5.97,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,41.13,58.75,,94.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.9,47,,57.056,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,32.9,47,,57.056,Percent of Total Billed Charges,47% of Total Billed Charges,3.95,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.95,41.13,
CEA,4018086,CDM,300,RC,82378,HCPCS,Outpatient,,,186.00,186.00,,109.28,58.75,,84.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,109.28,58.75,,84.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,90.04,48.41,,86.696,Percent of Total Billed Charges,48.41% of Total Billed Charges,23.18,100,,3.6,fee Schedule,100% of BCBS fee schedule,23.18,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,87.42,47,,84.168,Percent of Total Billed Charges,47% of Total Billed Charges,23.18,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,109.28,58.75,,84.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,87.42,47,,84.168,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,87.42,47,,84.168,Percent of Total Billed Charges,47% of Total Billed Charges,15.35,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15.35,109.28,
VMA,4018088,CDM,300,RC,84585,HCPCS,Outpatient,,,40.70,40.70,,23.91,58.75,,39.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.91,58.75,,39.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.7,48.41,,14.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.94,100,,3.6,fee Schedule,100% of BCBS fee schedule,18.94,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,19.13,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,18.94,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,23.91,58.75,,39.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.13,47,,14.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,19.13,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,12.56,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12.56,23.91,
FLU TEST,4018099,CDM,302,RC,87804,HCPCS,Outpatient,,,121.00,121.00,,71.09,58.75,,70.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,71.09,58.75,,70.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.58,48.41,,56.928,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.96,100,,13.68,fee Schedule,100% of BCBS fee schedule,16.96,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,56.87,47,,55.272,Percent of Total Billed Charges,47% of Total Billed Charges,16.96,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,71.09,58.75,,70.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,56.87,47,,55.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,56.87,47,,55.272,Percent of Total Billed Charges,47% of Total Billed Charges,13.41,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.41,71.09,
HDL CHOLESTEROL,4018105,CDM,301,RC,83718,HCPCS,Outpatient,,,64.00,64.00,,37.6,58.75,,45.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.6,58.75,,45.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.98,48.41,,16.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.01,100,,8.64,fee Schedule,100% of BCBS fee schedule,10.01,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,30.08,47,,16.168,Percent of Total Billed Charges,47% of Total Billed Charges,10.01,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,37.6,58.75,,45.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.08,47,,16.168,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,30.08,47,,16.168,Percent of Total Billed Charges,47% of Total Billed Charges,6.63,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.63,37.6,
CHEM 14,4018107,CDM,301,RC,80053,HCPCS,Outpatient,,,306.15,306.15,,179.86,58.75,,15.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,179.86,58.75,,15.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,148.21,48.41,,6.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.91,100,,8.64,fee Schedule,100% of BCBS fee schedule,12.91,100,,9.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,143.89,47,,6.68,Percent of Total Billed Charges,47% of Total Billed Charges,12.91,100,,9.36,Fee Schedule,100% of BCBS PPO fee schedule,179.86,58.75,,15.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,143.89,47,,6.68,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,143.89,47,,6.68,Percent of Total Billed Charges,47% of Total Billed Charges,8.55,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.55,179.86,
CPK,4018128,CDM,301,RC,82550,HCPCS,Outpatient,,,146.40,146.40,,86.01,58.75,,49.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.01,58.75,,49.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,70.87,48.41,,54.992,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.95,100,,8.64,fee Schedule,100% of BCBS fee schedule,7.95,100,,18,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,68.81,47,,53.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.95,100,,18,Fee Schedule,100% of BCBS PPO fee schedule,86.01,58.75,,49.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,68.81,47,,53.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,68.81,47,,53.392,Percent of Total Billed Charges,47% of Total Billed Charges,5.27,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.27,86.01,
CREATININE CLEAR,4018132,CDM,307,RC,82575,HCPCS,Outpatient,,,113.00,113.00,,66.39,58.75,,45.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.39,58.75,,45.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,54.7,48.41,,19.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.56,100,,3.6,fee Schedule,100% of BCBS fee schedule,11.56,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,53.11,47,,18.952,Percent of Total Billed Charges,47% of Total Billed Charges,11.56,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,66.39,58.75,,45.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,53.11,47,,18.952,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,53.11,47,,18.952,Percent of Total Billed Charges,47% of Total Billed Charges,7.66,90,,,Fee Schedule,90% of UHC fee schedule,53.11,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,53.11,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,7.66,66.39,
CREATININE,4018133,CDM,301,RC,82565,HCPCS,Outpatient,,,85.91,85.91,,50.47,58.75,,63.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.47,58.75,,63.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.59,48.41,,55.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.26,100,,3.6,fee Schedule,100% of BCBS fee schedule,6.26,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,40.38,47,,53.728,Percent of Total Billed Charges,47% of Total Billed Charges,6.26,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,50.47,58.75,,63.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.38,47,,53.728,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.38,47,,53.728,Percent of Total Billed Charges,47% of Total Billed Charges,4.15,90,,,Fee Schedule,90% of UHC fee schedule,40.38,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,40.38,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.15,50.47,
FERRITIN,4018176,CDM,300,RC,82728,HCPCS,Outpatient,,,134.00,134.00,,78.73,58.75,,87.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,78.73,58.75,,87.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.87,48.41,,25.984,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.67,100,,3.6,fee Schedule,100% of BCBS fee schedule,16.67,100,,13.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,62.98,47,,25.232,Percent of Total Billed Charges,47% of Total Billed Charges,16.67,100,,13.68,Fee Schedule,100% of BCBS PPO fee schedule,78.73,58.75,,87.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,62.98,47,,25.232,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,62.98,47,,25.232,Percent of Total Billed Charges,47% of Total Billed Charges,11.04,90,,,Fee Schedule,90% of UHC fee schedule,62.98,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,62.98,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,11.04,78.73,
FOLATE SERUM,4018184,CDM,300,RC,82746,HCPCS,Outpatient,,,143.75,143.75,,84.45,58.75,,36.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.45,58.75,,36.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.59,48.41,,34.856,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.97,100,,3.6,fee Schedule,100% of BCBS fee schedule,17.97,100,,8.64,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,67.56,47,,33.84,Percent of Total Billed Charges,47% of Total Billed Charges,17.97,100,,8.64,Fee Schedule,100% of BCBS PPO fee schedule,84.45,58.75,,36.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,67.56,47,,33.84,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,67.56,47,,33.84,Percent of Total Billed Charges,47% of Total Billed Charges,11.91,90,,,Fee Schedule,90% of UHC fee schedule,67.56,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,67.56,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,11.91,84.45,
FREE T4,4018189,CDM,301,RC,84439,HCPCS,Outpatient,,,57.00,57.00,,33.49,58.75,,70.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.49,58.75,,70.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.59,48.41,,109.216,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.02,100,,3.6,fee Schedule,100% of BCBS fee schedule,11.02,100,,8.64,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,26.79,47,,106.032,Percent of Total Billed Charges,47% of Total Billed Charges,11.02,100,,8.64,Fee Schedule,100% of BCBS PPO fee schedule,33.49,58.75,,70.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,106.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.79,47,,106.032,Percent of Total Billed Charges,47% of Total Billed Charges,7.31,90,,,Fee Schedule,90% of UHC fee schedule,26.79,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,26.79,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,7.31,33.49,
GAMMA GLUTA TRAN GGT,4018192,CDM,301,RC,82977,HCPCS,Outpatient,,,181.00,181.00,,106.34,58.75,,44.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,106.34,58.75,,44.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,87.62,48.41,,11.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.8,100,,3.6,fee Schedule,100% of BCBS fee schedule,8.8,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,85.07,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,8.8,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,106.34,58.75,,44.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,85.07,47,,11.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,85.07,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,5.83,90,,,Fee Schedule,90% of UHC fee schedule,85.07,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,85.07,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.83,106.34,
CA 27.29,4018199,CDM,300,RC,86300,HCPCS,Outpatient,,,169.00,169.00,,99.29,58.75,,44.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,99.29,58.75,,44.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,81.81,48.41,,48.8,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.44,100,,5.04,fee Schedule,100% of BCBS fee schedule,25.44,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,79.43,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,25.44,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,99.29,58.75,,44.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,79.43,47,,47.376,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,79.43,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,16.86,90,,,Fee Schedule,90% of UHC fee schedule,79.43,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,79.43,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,16.86,99.29,
GENTAMYCIN,4018200,CDM,301,RC,80170,HCPCS,Outpatient,,,198.45,198.45,,116.59,58.75,,53.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,116.59,58.75,,53.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.07,48.41,,49.472,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.02,100,,5.04,fee Schedule,100% of BCBS fee schedule,20.02,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,93.27,47,,48.032,Percent of Total Billed Charges,47% of Total Billed Charges,20.02,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,116.59,58.75,,53.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,93.27,47,,48.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,93.27,47,,48.032,Percent of Total Billed Charges,47% of Total Billed Charges,13.27,90,,,Fee Schedule,90% of UHC fee schedule,93.27,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,93.27,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,13.27,116.59,
GLUCOSE TOL 2HR,4018204,CDM,301,RC,82950,HCPCS,Outpatient,,,105.60,105.60,,62.04,58.75,,25.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.04,58.75,,25.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.12,48.41,,51.512,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.8,100,,38.88,fee Schedule,100% of BCBS fee schedule,5.8,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,49.63,47,,50.008,Percent of Total Billed Charges,47% of Total Billed Charges,5.8,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,62.04,58.75,,25.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.63,47,,50.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,49.63,47,,50.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.85,90,,,Fee Schedule,90% of UHC fee schedule,49.63,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,49.63,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,3.85,62.04,
GLUCOSE TOL 3HR,4018205,CDM,301,RC,82951,HCPCS,Outpatient,,,128.00,128.00,,75.2,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.2,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.96,48.41,,68.16,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.73,100,,3.6,fee Schedule,100% of BCBS fee schedule,15.73,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,60.16,47,,66.176,Percent of Total Billed Charges,47% of Total Billed Charges,15.73,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,75.2,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,60.16,47,,66.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,60.16,47,,66.176,Percent of Total Billed Charges,47% of Total Billed Charges,10.42,90,,,Fee Schedule,90% of UHC fee schedule,60.16,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,60.16,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,10.42,75.2,
GLUCOSE TOL 4HR,4018206,CDM,301,RC,82951,HCPCS,Outpatient,,,202.00,202.00,,118.68,58.75,,101.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,118.68,58.75,,101.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,97.79,48.41,,43.104,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.73,100,,3.6,fee Schedule,100% of BCBS fee schedule,15.73,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,94.94,47,,41.848,Percent of Total Billed Charges,47% of Total Billed Charges,15.73,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,118.68,58.75,,101.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,94.94,47,,41.848,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,94.94,47,,41.848,Percent of Total Billed Charges,47% of Total Billed Charges,10.42,90,,,Fee Schedule,90% of UHC fee schedule,94.94,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,94.94,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,10.42,118.68,
GLUCOSE TOL 5HR,4018207,CDM,301,RC,82951,HCPCS,Outpatient,,,180.00,180.00,,105.75,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,105.75,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,87.14,48.41,,49.96,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.73,100,,3.6,fee Schedule,100% of BCBS fee schedule,15.73,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,84.6,47,,48.504,Percent of Total Billed Charges,47% of Total Billed Charges,15.73,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,105.75,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,84.6,47,,48.504,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,84.6,47,,48.504,Percent of Total Billed Charges,47% of Total Billed Charges,10.42,90,,,Fee Schedule,90% of UHC fee schedule,84.6,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,84.6,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,10.42,105.75,
D-DIMER,4018208,CDM,300,RC,85379,HCPCS,Outpatient,,,83.50,83.50,,49.06,58.75,,66.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.06,58.75,,66.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.42,48.41,,68.16,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.44,100,,5.76,fee Schedule,100% of BCBS fee schedule,12.44,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,39.25,47,,66.176,Percent of Total Billed Charges,47% of Total Billed Charges,12.44,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,49.06,58.75,,66.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,39.25,47,,66.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,39.25,47,,66.176,Percent of Total Billed Charges,47% of Total Billed Charges,8.24,90,,,Fee Schedule,90% of UHC fee schedule,39.25,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,39.25,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.24,49.06,
GLUCOSE BLD SUGAR,4018213,CDM,301,RC,82947,HCPCS,Outpatient,,,150.45,150.45,,88.39,58.75,,64.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,88.39,58.75,,64.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,72.83,48.41,,15.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.81,100,,99.36,fee Schedule,100% of BCBS fee schedule,4.81,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,70.71,47,,15.416,Percent of Total Billed Charges,47% of Total Billed Charges,4.81,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,88.39,58.75,,64.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,70.71,47,,15.416,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,70.71,47,,15.416,Percent of Total Billed Charges,47% of Total Billed Charges,3.19,90,,,Fee Schedule,90% of UHC fee schedule,70.71,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,70.71,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,3.19,88.39,
HSV 1 & 2 ANTIBODIES IGM,4018214,CDM,302,RC,86694,HCPCS,Outpatient,,,96.00,96.00,,56.4,58.75,,95.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,56.4,58.75,,95.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.47,48.41,,69.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.59,100,,3.6,fee Schedule,100% of BCBS fee schedule,17.59,100,,38.88,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,45.12,47,,67.304,Percent of Total Billed Charges,47% of Total Billed Charges,17.59,100,,38.88,Fee Schedule,100% of BCBS PPO fee schedule,56.4,58.75,,95.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.12,47,,67.304,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,45.12,47,,67.304,Percent of Total Billed Charges,47% of Total Billed Charges,11.66,90,,,Fee Schedule,90% of UHC fee schedule,45.12,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,45.12,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,11.66,56.4,
HEPATITIS B SURF ANT,4018239,CDM,302,RC,86706,HCPCS,Outpatient,,,34.00,34.00,,19.98,58.75,,200.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.98,58.75,,200.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.46,48.41,,38.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.12,100,,3.96,fee Schedule,100% of BCBS fee schedule,13.12,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,15.98,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,13.12,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,19.98,58.75,,200.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.98,47,,37.6,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.98,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,8.7,90,,,Fee Schedule,90% of UHC fee schedule,15.98,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,15.98,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.7,19.98,
IRON SERUM,4018264,CDM,301,RC,83540,HCPCS,Outpatient,,,105.45,105.45,,61.95,58.75,,101.848,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.95,58.75,,101.848,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.05,48.41,,46.472,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.91,100,,3.6,fee Schedule,100% of BCBS fee schedule,7.91,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,49.56,47,,45.12,Percent of Total Billed Charges,47% of Total Billed Charges,7.91,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,61.95,58.75,,101.848,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.56,47,,45.12,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,49.56,47,,45.12,Percent of Total Billed Charges,47% of Total Billed Charges,5.24,90,,,Fee Schedule,90% of UHC fee schedule,49.56,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,49.56,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.24,61.95,
IRON BINDING CAPACIT,4018265,CDM,301,RC,83550,HCPCS,Outpatient,,,95.85,95.85,,56.31,58.75,,78.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,56.31,58.75,,78.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.4,48.41,,48.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.68,100,,3.96,fee Schedule,100% of BCBS fee schedule,10.68,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,45.05,47,,47.152,Percent of Total Billed Charges,47% of Total Billed Charges,10.68,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,56.31,58.75,,78.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.05,47,,47.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,45.05,47,,47.152,Percent of Total Billed Charges,47% of Total Billed Charges,7.08,90,,,Fee Schedule,90% of UHC fee schedule,45.05,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,45.05,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,7.08,56.31,
LDH LACTATE DEHYDROG,4018282,CDM,301,RC,83615,HCPCS,Outpatient,,,135.00,135.00,,79.31,58.75,,164.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.31,58.75,,164.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,65.35,48.41,,55.768,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.38,100,,3.6,fee Schedule,100% of BCBS fee schedule,7.38,100,,5.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,63.45,47,,54.144,Percent of Total Billed Charges,47% of Total Billed Charges,7.38,100,,5.76,Fee Schedule,100% of BCBS PPO fee schedule,79.31,58.75,,164.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,63.45,47,,54.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,63.45,47,,54.144,Percent of Total Billed Charges,47% of Total Billed Charges,4.9,90,,,Fee Schedule,90% of UHC fee schedule,63.45,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,63.45,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.9,79.31,
LEAD QUANT SERIES,4018285,CDM,300,RC,83655,HCPCS,Outpatient,,,186.35,186.35,,109.48,58.75,,71.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,109.48,58.75,,71.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,90.21,48.41,,17.04,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.8,100,,4.32,fee Schedule,100% of BCBS fee schedule,14.8,100,,99.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,87.58,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,14.8,100,,99.36,Fee Schedule,100% of BCBS PPO fee schedule,109.48,58.75,,71.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,87.58,47,,16.544,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,87.58,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,9.81,90,,,Fee Schedule,90% of UHC fee schedule,87.58,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,87.58,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,9.81,109.48,
LIPASE,4018288,CDM,301,RC,83690,HCPCS,Outpatient,,,78.10,78.10,,45.88,58.75,,49.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.88,58.75,,49.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.81,48.41,,46.088,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.42,100,,3.6,fee Schedule,100% of BCBS fee schedule,8.42,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,36.71,47,,44.744,Percent of Total Billed Charges,47% of Total Billed Charges,8.42,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,45.88,58.75,,49.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,36.71,47,,44.744,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,36.71,47,,44.744,Percent of Total Billed Charges,47% of Total Billed Charges,5.58,90,,,Fee Schedule,90% of UHC fee schedule,36.71,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,36.71,47,,20.304,Percent of Total Billed Charges,47% of Total Billed Charges,5.58,45.88,
LITHIUM,4018293,CDM,301,RC,80178,HCPCS,Outpatient,,,100.10,100.10,,58.81,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.81,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.46,48.41,,40.896,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.09,100,,3.6,fee Schedule,100% of BCBS fee schedule,8.09,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,47.05,47,,39.704,Percent of Total Billed Charges,47% of Total Billed Charges,8.09,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,58.81,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47.05,47,,39.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47.05,47,,39.704,Percent of Total Billed Charges,47% of Total Billed Charges,5.36,90,,,Fee Schedule,90% of UHC fee schedule,47.05,47,,20.304,Percent of Total Billed Charges,47% of Total Billed Charges,47.05,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.36,58.81,
LYMES TEST,4018294,CDM,302,RC,86618,HCPCS,Outpatient,,,150.00,150.00,,88.13,58.75,,36.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,88.13,58.75,,36.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,72.62,48.41,,25.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.81,100,,3.6,fee Schedule,100% of BCBS fee schedule,20.81,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,70.5,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,20.81,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,88.13,58.75,,36.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,70.5,47,,24.816,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,70.5,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,13.8,90,,,Fee Schedule,90% of UHC fee schedule,70.5,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,70.5,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,13.8,88.13,
MAGNESIUM (MG),4018298,CDM,301,RC,83735,HCPCS,Outpatient,,,93.70,93.70,,55.05,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,55.05,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.36,48.41,,37.176,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.18,100,,4.32,fee Schedule,100% of BCBS fee schedule,8.18,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,44.04,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,8.18,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,55.05,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,44.04,47,,36.096,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,44.04,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,5.43,90,,,Fee Schedule,90% of UHC fee schedule,44.04,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,44.04,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.43,55.05,
MYOGLOBIN,4018320,CDM,301,RC,83874,HCPCS,Outpatient,,,95.00,95.00,,55.81,58.75,,76.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,55.81,58.75,,76.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.99,48.41,,34.856,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.79,100,,3.6,fee Schedule,100% of BCBS fee schedule,15.79,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,44.65,47,,33.84,Percent of Total Billed Charges,47% of Total Billed Charges,15.79,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,55.81,58.75,,76.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,44.65,47,,33.84,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,44.65,47,,33.84,Percent of Total Billed Charges,47% of Total Billed Charges,10.47,90,,,Fee Schedule,90% of UHC fee schedule,44.65,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,44.65,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,10.47,55.81,
OSMOLALITY,4018333,CDM,300,RC,83930,HCPCS,Outpatient,,,114.00,114.00,,66.98,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.98,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,55.19,48.41,,47.248,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.09,100,,3.6,fee Schedule,100% of BCBS fee schedule,8.09,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,53.58,47,,45.872,Percent of Total Billed Charges,47% of Total Billed Charges,8.09,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,66.98,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,53.58,47,,45.872,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,53.58,47,,45.872,Percent of Total Billed Charges,47% of Total Billed Charges,5.36,90,,,Fee Schedule,90% of UHC fee schedule,53.58,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,53.58,47,,51.888,Percent of Total Billed Charges,47% of Total Billed Charges,5.36,66.98,
NEUONTIN GABOPONTIN,4018347,CDM,301,RC,80171,HCPCS,Outpatient,,,53.25,53.25,,31.28,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.28,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.78,48.41,,14.056,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.21,100,,27.36,fee Schedule,100% of BCBS fee schedule,22.21,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,25.03,47,,13.648,Percent of Total Billed Charges,47% of Total Billed Charges,22.21,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,31.28,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,25.03,47,,13.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,25.03,47,,13.648,Percent of Total Billed Charges,47% of Total Billed Charges,17.55,90,,,Fee Schedule,90% of UHC fee schedule,25.03,47,,51.888,Percent of Total Billed Charges,47% of Total Billed Charges,25.03,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,17.55,31.28,
PHENOBARB,4018352,CDM,301,RC,80184,HCPCS,Outpatient,,,159.00,159.00,,93.41,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,93.41,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.97,48.41,,14.056,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.68,100,,69.84,fee Schedule,100% of BCBS fee schedule,15.68,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,74.73,47,,13.648,Percent of Total Billed Charges,47% of Total Billed Charges,15.68,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,93.41,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,74.73,47,,13.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,74.73,47,,13.648,Percent of Total Billed Charges,47% of Total Billed Charges,12.39,90,,,Fee Schedule,90% of UHC fee schedule,74.73,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,74.73,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,12.39,93.41,
DILANTIN,4018358,CDM,301,RC,80185,HCPCS,Outpatient,,,215.00,215.00,,126.31,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,126.31,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,104.08,48.41,,28.12,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.2,100,,4.32,fee Schedule,100% of BCBS fee schedule,16.2,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,101.05,47,,27.296,Percent of Total Billed Charges,47% of Total Billed Charges,16.2,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,126.31,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,101.05,47,,27.296,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,101.05,47,,27.296,Percent of Total Billed Charges,47% of Total Billed Charges,10.74,90,,,Fee Schedule,90% of UHC fee schedule,101.05,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,101.05,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,10.74,126.31,
PHOSPHATESE ALKALINE,4018359,CDM,301,RC,84075,HCPCS,Outpatient,,,79.00,79.00,,46.41,58.75,,60.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.41,58.75,,60.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.24,48.41,,45.544,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.33,100,,3.6,fee Schedule,100% of BCBS fee schedule,6.33,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,37.13,47,,44.216,Percent of Total Billed Charges,47% of Total Billed Charges,6.33,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,46.41,58.75,,60.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.13,47,,44.216,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,37.13,47,,44.216,Percent of Total Billed Charges,47% of Total Billed Charges,4.19,90,,,Fee Schedule,90% of UHC fee schedule,37.13,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,37.13,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,4.19,46.41,
CHLAMYDIA,4018362,CDM,306,RC,87491,HCPCS,Outpatient,,,141.00,141.00,,82.84,58.75,,41.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,82.84,58.75,,41.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,68.26,48.41,,30.984,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.89,100,,6.48,fee Schedule,100% of BCBS fee schedule,42.89,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,66.27,47,,30.08,Percent of Total Billed Charges,47% of Total Billed Charges,42.89,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,82.84,58.75,,41.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,66.27,47,,30.08,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,66.27,47,,30.08,Percent of Total Billed Charges,47% of Total Billed Charges,28.42,90,,,Fee Schedule,90% of UHC fee schedule,66.27,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,66.27,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,28.42,82.84,
PHOSPHORUS SERUM,4018366,CDM,301,RC,84100,HCPCS,Outpatient,,,137.00,137.00,,80.49,58.75,,62.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,80.49,58.75,,62.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.32,48.41,,74.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.8,100,,33.84,fee Schedule,100% of BCBS fee schedule,5.8,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,64.39,47,,72.568,Percent of Total Billed Charges,47% of Total Billed Charges,5.8,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,80.49,58.75,,62.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,64.39,47,,72.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,64.39,47,,72.568,Percent of Total Billed Charges,47% of Total Billed Charges,3.84,90,,,Fee Schedule,90% of UHC fee schedule,64.39,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,64.39,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,3.84,80.49,
POTASSIUM,4018375,CDM,301,RC,84132,HCPCS,Outpatient,,,203.00,203.00,,119.26,58.75,,32.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,119.26,58.75,,32.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,98.27,48.41,,80.944,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.62,100,,37.44,fee Schedule,100% of BCBS fee schedule,5.62,100,,27.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,95.41,47,,78.584,Percent of Total Billed Charges,47% of Total Billed Charges,5.62,100,,27.36,Fee Schedule,100% of BCBS PPO fee schedule,119.26,58.75,,32.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,95.41,47,,78.584,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,95.41,47,,78.584,Percent of Total Billed Charges,47% of Total Billed Charges,3.85,90,,,Fee Schedule,90% of UHC fee schedule,95.41,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,95.41,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,3.85,119.26,
PROFILE ELECTROLITE1,4018383,CDM,301,RC,80051,HCPCS,Outpatient,,,425.60,425.60,,250.04,58.75,,88.832,Percent of Total Billed Charges,58.75% of Total Billed Charges,250.04,58.75,,88.832,Percent of Total Billed Charges,58.75% of Total Billed Charges,206.03,48.41,,14.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.57,100,,73.44,fee Schedule,100% of BCBS fee schedule,8.57,100,,69.84,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,200.03,47,,14.44,Percent of Total Billed Charges,47% of Total Billed Charges,8.57,100,,69.84,Fee Schedule,100% of BCBS PPO fee schedule,250.04,58.75,,88.832,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,200.03,47,,14.44,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,200.03,47,,14.44,Percent of Total Billed Charges,47% of Total Billed Charges,5.68,90,,,Fee Schedule,90% of UHC fee schedule,200.03,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,200.03,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.68,250.04,
CHEM 8,4018391,CDM,301,RC,80048,HCPCS,Outpatient,,,216.70,216.70,,127.31,58.75,,71.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,127.31,58.75,,71.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,104.9,48.41,,79.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.34,100,,4.752,fee Schedule,100% of BCBS fee schedule,10.34,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,101.85,47,,77.496,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,127.31,58.75,,71.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,101.85,47,,77.496,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,101.85,47,,77.496,Percent of Total Billed Charges,47% of Total Billed Charges,6.85,90,,,Fee Schedule,90% of UHC fee schedule,101.85,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,101.85,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.85,127.31,
RENAL FUNCTION PANEL,4018393,CDM,301,RC,80069,HCPCS,Outpatient,,,167.00,167.00,,98.11,58.75,,105.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,98.11,58.75,,105.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,80.84,48.41,,50.736,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.62,100,,43.92,fee Schedule,100% of BCBS fee schedule,10.62,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,78.49,47,,49.256,Percent of Total Billed Charges,47% of Total Billed Charges,10.62,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,98.11,58.75,,105.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,78.49,47,,49.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,78.49,47,,49.256,Percent of Total Billed Charges,47% of Total Billed Charges,7.03,90,,,Fee Schedule,90% of UHC fee schedule,78.49,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,78.49,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,7.03,98.11,
ACUTE HEPATITISPAN,4018401,CDM,302,RC,80074,HCPCS,Outpatient,,,350.00,350.00,,205.63,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,205.63,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,169.44,48.41,,32.064,Percent of Total Billed Charges,48.41% of Total Billed Charges,58.22,100,,43.92,fee Schedule,100% of BCBS fee schedule,58.22,100,,6.48,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,164.5,47,,31.136,Percent of Total Billed Charges,47% of Total Billed Charges,58.22,100,,6.48,Fee Schedule,100% of BCBS PPO fee schedule,205.63,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,164.5,47,,31.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,164.5,47,,31.136,Percent of Total Billed Charges,47% of Total Billed Charges,38.58,90,,,Fee Schedule,90% of UHC fee schedule,164.5,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,164.5,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,38.58,205.63,
LIPID PANEL,4018403,CDM,301,RC,80061,HCPCS,Outpatient,,,151.25,151.25,,88.86,58.75,,69.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,88.86,58.75,,69.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.22,48.41,,79.296,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.37,100,,13.68,fee Schedule,100% of BCBS fee schedule,16.37,100,,33.84,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,71.09,47,,76.984,Percent of Total Billed Charges,47% of Total Billed Charges,16.37,100,,33.84,Fee Schedule,100% of BCBS PPO fee schedule,88.86,58.75,,69.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,71.09,47,,76.984,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,71.09,47,,76.984,Percent of Total Billed Charges,47% of Total Billed Charges,10.85,90,,,Fee Schedule,90% of UHC fee schedule,71.09,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,71.09,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,10.85,88.86,
PROTEIN ELECTROPHORESIS,4018421,CDM,300,RC,84165,HCPCS,Outpatient,,,106.00,106.00,,62.28,58.75,,20.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.28,58.75,,20.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.31,48.41,,17.64,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.12,100,,3.6,fee Schedule,100% of BCBS fee schedule,13.12,100,,37.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,49.82,47,,17.128,Percent of Total Billed Charges,47% of Total Billed Charges,13.12,100,,37.44,Fee Schedule,100% of BCBS PPO fee schedule,62.28,58.75,,20.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.82,47,,17.128,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,49.82,47,,17.128,Percent of Total Billed Charges,47% of Total Billed Charges,8.7,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.7,62.28,
PROTEIN SPINAL FLUID,4018425,CDM,300,RC,84157,HCPCS,Outpatient,,,47.00,47.00,,27.61,58.75,,8.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.61,58.75,,8.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.75,48.41,,37.76,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.48,100,,6.48,fee Schedule,100% of BCBS fee schedule,4.48,100,,73.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,22.09,47,,36.664,Percent of Total Billed Charges,47% of Total Billed Charges,4.48,100,,73.44,Fee Schedule,100% of BCBS PPO fee schedule,27.61,58.75,,8.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,36.664,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,22.09,47,,36.664,Percent of Total Billed Charges,47% of Total Billed Charges,3.24,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.24,27.61,
PROTEIN TOTAL,4018426,CDM,301,RC,84155,HCPCS,Outpatient,,,78.00,78.00,,45.83,58.75,,66.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.83,58.75,,66.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.76,48.41,,38.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.48,100,,3.6,fee Schedule,100% of BCBS fee schedule,4.48,100,,4.752,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,36.66,47,,37.672,Percent of Total Billed Charges,47% of Total Billed Charges,4.48,100,,4.752,Fee Schedule,100% of BCBS PPO fee schedule,45.83,58.75,,66.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,36.66,47,,37.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,36.66,47,,37.672,Percent of Total Billed Charges,47% of Total Billed Charges,2.97,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.97,45.83,
PROTEIN URINE QT 24H,4018428,CDM,307,RC,84156,HCPCS,Outpatient,,,64.00,64.00,,37.6,58.75,,23.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.6,58.75,,23.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.98,48.41,,64.288,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.48,100,,23.04,fee Schedule,100% of BCBS fee schedule,4.48,100,,43.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,30.08,47,,62.416,Percent of Total Billed Charges,47% of Total Billed Charges,4.48,100,,43.92,Fee Schedule,100% of BCBS PPO fee schedule,37.6,58.75,,23.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.08,47,,62.416,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,30.08,47,,62.416,Percent of Total Billed Charges,47% of Total Billed Charges,2.97,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.97,37.6,
"CKMB (CE, CARDIAC ENZYMES)",4018435,CDM,301,RC,82553,HCPCS,Outpatient,,,162.40,162.40,,95.41,58.75,,67.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,95.41,58.75,,67.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,78.62,48.41,,23.272,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.11,100,,3.6,fee Schedule,100% of BCBS fee schedule,14.11,100,,43.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,76.33,47,,22.592,Percent of Total Billed Charges,47% of Total Billed Charges,14.11,100,,43.92,Fee Schedule,100% of BCBS PPO fee schedule,95.41,58.75,,67.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,76.33,47,,22.592,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,76.33,47,,22.592,Percent of Total Billed Charges,47% of Total Billed Charges,9.36,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9.36,95.41,
SODIUM,4018445,CDM,301,RC,84295,HCPCS,Outpatient,,,94.00,94.00,,55.23,58.75,,31.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,55.23,58.75,,31.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.51,48.41,,75.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.89,100,,71.28,fee Schedule,100% of BCBS fee schedule,5.89,100,,13.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,44.18,47,,73.656,Percent of Total Billed Charges,47% of Total Billed Charges,5.89,100,,13.68,Fee Schedule,100% of BCBS PPO fee schedule,55.23,58.75,,31.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,44.18,47,,73.656,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,44.18,47,,73.656,Percent of Total Billed Charges,47% of Total Billed Charges,3.9,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.9,55.23,
THEOPHYLLINE,4018461,CDM,301,RC,80198,HCPCS,Outpatient,,,126.00,126.00,,74.03,58.75,,42.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.03,58.75,,42.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,61,48.41,,81.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.28,100,,3.6,fee Schedule,100% of BCBS fee schedule,17.28,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,59.22,47,,78.96,Percent of Total Billed Charges,47% of Total Billed Charges,17.28,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,74.03,58.75,,42.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,59.22,47,,78.96,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,59.22,47,,78.96,Percent of Total Billed Charges,47% of Total Billed Charges,11.46,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.46,74.03,
TRANSAMINASE SGOT,4018471,CDM,301,RC,84450,HCPCS,Outpatient,,,71.00,71.00,,41.71,58.75,,156.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.71,58.75,,156.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.37,48.41,,13.432,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.33,100,,28.8,fee Schedule,100% of BCBS fee schedule,6.33,100,,6.48,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,33.37,47,,13.04,Percent of Total Billed Charges,47% of Total Billed Charges,6.33,100,,6.48,Fee Schedule,100% of BCBS PPO fee schedule,41.71,58.75,,156.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.37,47,,13.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,33.37,47,,13.04,Percent of Total Billed Charges,47% of Total Billed Charges,4.19,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.19,41.71,
TRANSAMINASE SGPT,4018472,CDM,301,RC,84460,HCPCS,Outpatient,,,69.00,69.00,,40.54,58.75,,132.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.54,58.75,,132.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.4,48.41,,103.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.48,100,,3.6,fee Schedule,100% of BCBS fee schedule,6.48,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,32.43,47,,100.32,Percent of Total Billed Charges,47% of Total Billed Charges,6.48,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,40.54,58.75,,132.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.43,47,,100.32,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,32.43,47,,100.32,Percent of Total Billed Charges,47% of Total Billed Charges,4.29,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.29,40.54,
TRIGLYCERIDES,4018476,CDM,301,RC,84478,HCPCS,Outpatient,,,128.00,128.00,,75.2,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.2,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.96,48.41,,125.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.02,100,,30.24,fee Schedule,100% of BCBS fee schedule,7.02,100,,23.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,60.16,47,,121.824,Percent of Total Billed Charges,47% of Total Billed Charges,7.02,100,,23.04,Fee Schedule,100% of BCBS PPO fee schedule,75.2,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,60.16,47,,121.824,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,60.16,47,,121.824,Percent of Total Billed Charges,47% of Total Billed Charges,4.65,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.65,75.2,
T-3 UPTAKE,4018477,CDM,301,RC,84479,HCPCS,Outpatient,,,88.00,88.00,,51.7,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.7,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.6,48.41,,11.544,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.9,100,,17.28,fee Schedule,100% of BCBS fee schedule,7.9,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,41.36,47,,11.208,Percent of Total Billed Charges,47% of Total Billed Charges,7.9,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,51.7,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,41.36,47,,11.208,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,41.36,47,,11.208,Percent of Total Billed Charges,47% of Total Billed Charges,5.24,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.24,51.7,
BUN,4018486,CDM,300,RC,84520,HCPCS,Outpatient,,,133.10,133.10,,78.2,58.75,,60.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,78.2,58.75,,60.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.43,48.41,,13.232,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.83,100,,5.76,fee Schedule,100% of BCBS fee schedule,4.83,100,,71.28,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,62.56,47,,12.848,Percent of Total Billed Charges,47% of Total Billed Charges,4.83,100,,71.28,Fee Schedule,100% of BCBS PPO fee schedule,78.2,58.75,,60.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,62.56,47,,12.848,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,62.56,47,,12.848,Percent of Total Billed Charges,47% of Total Billed Charges,3.2,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.2,78.2,
URIC ACID BLOOD,4018491,CDM,301,RC,84550,HCPCS,Outpatient,,,68.95,68.95,,40.51,58.75,,62.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.51,58.75,,62.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.38,48.41,,50.736,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.52,100,,10.8,fee Schedule,100% of BCBS fee schedule,5.52,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,32.41,47,,49.256,Percent of Total Billed Charges,47% of Total Billed Charges,5.52,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,40.51,58.75,,62.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.41,47,,49.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,32.41,47,,49.256,Percent of Total Billed Charges,47% of Total Billed Charges,3.66,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.66,40.51,
DEPAKOTE,4018496,CDM,300,RC,80164,HCPCS,Outpatient,,,189.00,189.00,,111.04,58.75,,82.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,111.04,58.75,,82.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,91.49,48.41,,43.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.56,100,,3.6,fee Schedule,100% of BCBS fee schedule,16.56,100,,28.8,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,88.83,47,,42.304,Percent of Total Billed Charges,47% of Total Billed Charges,16.56,100,,28.8,Fee Schedule,100% of BCBS PPO fee schedule,111.04,58.75,,82.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,88.83,47,,42.304,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,88.83,47,,42.304,Percent of Total Billed Charges,47% of Total Billed Charges,10.97,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.97,111.04,
VITAMIN B-12,4018502,CDM,301,RC,82607,HCPCS,Outpatient,,,151.75,151.75,,89.15,58.75,,52.312,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.15,58.75,,52.312,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.46,48.41,,40.664,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.43,100,,195.12,fee Schedule,100% of BCBS fee schedule,18.43,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,71.32,47,,39.48,Percent of Total Billed Charges,47% of Total Billed Charges,18.43,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,89.15,58.75,,52.312,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,71.32,47,,39.48,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,71.32,47,,39.48,Percent of Total Billed Charges,47% of Total Billed Charges,12.21,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12.21,89.15,
DIGOXIN,4018520,CDM,300,RC,80162,HCPCS,Outpatient,,,223.85,223.85,,131.51,58.75,,60.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,131.51,58.75,,60.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,108.37,48.41,,8.704,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.23,100,,12.96,fee Schedule,100% of BCBS fee schedule,16.23,100,,30.24,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,105.21,47,,8.456,Percent of Total Billed Charges,47% of Total Billed Charges,16.23,100,,30.24,Fee Schedule,100% of BCBS PPO fee schedule,131.51,58.75,,60.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,105.21,47,,8.456,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,105.21,47,,8.456,Percent of Total Billed Charges,47% of Total Billed Charges,10.76,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.76,131.51,
HCG QUANTITATIVE,4018528,CDM,300,RC,84702,HCPCS,Outpatient,,,38.00,38.00,,22.33,58.75,,19.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.33,58.75,,19.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.4,48.41,,82.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.4,100,,3.96,fee Schedule,100% of BCBS fee schedule,18.4,100,,5.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,17.86,47,,80.424,Percent of Total Billed Charges,47% of Total Billed Charges,18.4,100,,5.76,Fee Schedule,100% of BCBS PPO fee schedule,22.33,58.75,,19.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,80.424,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.86,47,,80.424,Percent of Total Billed Charges,47% of Total Billed Charges,12.2,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12.2,22.33,
CHOLESTEROL,4018535,CDM,301,RC,82465,HCPCS,Outpatient,,,147.00,147.00,,86.36,58.75,,84.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.36,58.75,,84.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,71.16,48.41,,43.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.32,100,,3.6,fee Schedule,100% of BCBS fee schedule,5.32,100,,10.8,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,69.09,47,,42.184,Percent of Total Billed Charges,47% of Total Billed Charges,5.32,100,,10.8,Fee Schedule,100% of BCBS PPO fee schedule,86.36,58.75,,84.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,69.09,47,,42.184,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,69.09,47,,42.184,Percent of Total Billed Charges,47% of Total Billed Charges,3.53,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.53,86.36,
ALPHA-FETOPROTEIN MARKER,4018547,CDM,301,RC,82105,HCPCS,Outpatient,,,43.00,43.00,,25.26,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.26,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.82,48.41,,43.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.5,100,,5.04,fee Schedule,100% of BCBS fee schedule,20.5,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,20.21,47,,42.184,Percent of Total Billed Charges,47% of Total Billed Charges,20.5,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,25.26,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.21,47,,42.184,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,20.21,47,,42.184,Percent of Total Billed Charges,47% of Total Billed Charges,13.58,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.58,25.26,
C-PEPTIDE,4018548,CDM,301,RC,84681,HCPCS,Outpatient,,,17.77,17.77,,10.44,58.75,,56.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.44,58.75,,56.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.6,48.41,,11.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.44,100,,131.76,fee Schedule,100% of BCBS fee schedule,25.44,100,,195.12,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,8.35,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,25.44,100,,195.12,Fee Schedule,100% of BCBS PPO fee schedule,10.44,58.75,,56.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.35,47,,11.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.35,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,16.86,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.35,25.44,
VITAMIN D (OH 25),4018549,CDM,301,RC,82306,HCPCS,Outpatient,,,142.00,142.00,,83.43,58.75,,58.936,Percent of Total Billed Charges,58.75% of Total Billed Charges,83.43,58.75,,58.936,Percent of Total Billed Charges,58.75% of Total Billed Charges,68.74,48.41,,69.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,36.18,100,,9.504,fee Schedule,100% of BCBS fee schedule,36.18,100,,12.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,66.74,47,,67.304,Percent of Total Billed Charges,47% of Total Billed Charges,36.18,100,,12.96,Fee Schedule,100% of BCBS PPO fee schedule,83.43,58.75,,58.936,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,66.74,47,,67.304,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,66.74,47,,67.304,Percent of Total Billed Charges,47% of Total Billed Charges,23.98,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23.98,83.43,
PROINSULIN,4018565,CDM,301,RC,84206,HCPCS,Outpatient,,,50.40,50.40,,29.61,58.75,,67.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.61,58.75,,67.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.4,48.41,,74.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,27.36,100,,43.92,fee Schedule,100% of BCBS fee schedule,27.36,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,23.69,47,,72.192,Percent of Total Billed Charges,47% of Total Billed Charges,27.36,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,29.61,58.75,,67.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.69,47,,72.192,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.69,47,,72.192,Percent of Total Billed Charges,47% of Total Billed Charges,21.62,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21.62,29.61,
SPECIAL STAINS,4018566,CDM,310,RC,88312,HCPCS,Outpatient,,,142.89,142.89,TC,83.95,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,83.95,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.17,48.41,,6.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,45.01,100,,28.8,fee Schedule,100% of BCBS fee schedule,45.01,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,67.16,47,,5.952,Percent of Total Billed Charges,47% of Total Billed Charges,45.01,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,83.95,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,67.16,47,,5.952,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,67.16,47,,5.952,Percent of Total Billed Charges,47% of Total Billed Charges,41.11,90,,,Fee Schedule,90% of UHC fee schedule,109.6,115,,9.024,Fee Schedule,115% of CMS OPPS Rate,109.6,115,,3.008,Fee Schedule,115% of CMS OPPS Rate,41.11,109.6,
CHLORIDE,4018567,CDM,301,RC,82435,HCPCS,Outpatient,,,67.10,67.10,,39.42,58.75,,55.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.42,58.75,,55.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.48,48.41,,14.984,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.62,100,,43.92,fee Schedule,100% of BCBS fee schedule,5.62,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,31.54,47,,14.552,Percent of Total Billed Charges,47% of Total Billed Charges,5.62,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,39.42,58.75,,55.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.54,47,,14.552,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.54,47,,14.552,Percent of Total Billed Charges,47% of Total Billed Charges,3.73,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.73,39.42,
COTININE,4018568,CDM,300,RC,80323,HCPCS,Outpatient,,,90.00,90.00,,52.88,58.75,,49.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,52.88,58.75,,49.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,43.57,48.41,,17.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,64.25,100,,33.84,fee Schedule,100% of BCBS fee schedule,64.25,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,42.3,47,,17.144,Percent of Total Billed Charges,47% of Total Billed Charges,64.25,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,52.88,58.75,,49.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,42.3,47,,17.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,42.3,47,,17.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,42.3,64.25,
ESTROGEN,4018569,CDM,301,RC,82672,HCPCS,Outpatient,,,332.00,332.00,,195.05,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,195.05,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,160.72,48.41,,20.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,26.52,100,,43.92,fee Schedule,100% of BCBS fee schedule,26.52,100,,131.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,156.04,47,,20.264,Percent of Total Billed Charges,47% of Total Billed Charges,26.52,100,,131.76,Fee Schedule,100% of BCBS PPO fee schedule,195.05,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,156.04,47,,20.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,156.04,47,,20.264,Percent of Total Billed Charges,47% of Total Billed Charges,17.58,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17.58,195.05,
GC/CHLAM AMP PROBE,4018570,CDM,306,RC,87491,HCPCS,Outpatient,,,282.00,282.00,,165.68,58.75,,45.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,165.68,58.75,,45.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,136.52,48.41,,53.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.89,100,,21.6,fee Schedule,100% of BCBS fee schedule,42.89,100,,9.504,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,132.54,47,,51.96,Percent of Total Billed Charges,47% of Total Billed Charges,42.89,100,,9.504,Fee Schedule,100% of BCBS PPO fee schedule,165.68,58.75,,45.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,132.54,47,,51.96,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,132.54,47,,51.96,Percent of Total Billed Charges,47% of Total Billed Charges,28.42,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28.42,165.68,
DRUG SCREEN COLLECTION-COC,4018574,CDM,300,RC,,,Outpatient,,,30.00,30.00,,17.63,58.75,,42.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.63,58.75,,42.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.52,48.41,,39.04,Percent of Total Billed Charges,48.41% of Total Billed Charges,27,90,,113.04,Percent of Total Billed Charges,90% of Total Billed Charges,27,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,47,,37.904,Percent of Total Billed Charges,47% of Total Billed Charges,27,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,17.63,58.75,,42.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,37.904,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.1,47,,37.904,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14.1,27,
DRUG SCREEN-REFERENCE LAB,4018575,CDM,300,RC,80307,HCPCS,Outpatient,,,126.00,126.00,,74.03,58.75,,57.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.03,58.75,,57.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,61,48.41,,14.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,71.12,100,,4.32,fee Schedule,100% of BCBS fee schedule,71.12,100,,28.8,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,59.22,47,,14.128,Percent of Total Billed Charges,47% of Total Billed Charges,71.12,100,,28.8,Fee Schedule,100% of BCBS PPO fee schedule,74.03,58.75,,57.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,59.22,47,,14.128,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,59.22,47,,14.128,Percent of Total Billed Charges,47% of Total Billed Charges,50.34,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50.34,74.03,
CULTURE WOUND,4018576,CDM,306,RC,87070,HCPCS,Outpatient,,,127.75,127.75,,75.05,58.75,,17.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.05,58.75,,17.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.84,48.41,,32.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.53,100,,7.92,fee Schedule,100% of BCBS fee schedule,10.53,100,,43.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,60.04,47,,31.696,Percent of Total Billed Charges,47% of Total Billed Charges,10.53,100,,43.92,Fee Schedule,100% of BCBS PPO fee schedule,75.05,58.75,,17.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,60.04,47,,31.696,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,60.04,47,,31.696,Percent of Total Billed Charges,47% of Total Billed Charges,6.98,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.98,75.05,
CHROMIUM,4018577,CDM,301,RC,82495,HCPCS,Outpatient,,,133.00,133.00,,78.14,58.75,,17.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,78.14,58.75,,17.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.39,48.41,,13.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,24.78,100,,25.92,fee Schedule,100% of BCBS fee schedule,24.78,100,,33.84,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,62.51,47,,13.176,Percent of Total Billed Charges,47% of Total Billed Charges,24.78,100,,33.84,Fee Schedule,100% of BCBS PPO fee schedule,78.14,58.75,,17.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,62.51,47,,13.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,62.51,47,,13.176,Percent of Total Billed Charges,47% of Total Billed Charges,16.43,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.43,78.14,
COBALT,4018578,CDM,301,RC,83018,HCPCS,Outpatient,,,176.00,176.00,,103.4,58.75,,34.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,103.4,58.75,,34.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,85.2,48.41,,59.832,Percent of Total Billed Charges,48.41% of Total Billed Charges,26.85,100,,4.32,fee Schedule,100% of BCBS fee schedule,26.85,100,,43.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,82.72,47,,58.096,Percent of Total Billed Charges,47% of Total Billed Charges,26.85,100,,43.92,Fee Schedule,100% of BCBS PPO fee schedule,103.4,58.75,,34.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,82.72,47,,58.096,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,82.72,47,,58.096,Percent of Total Billed Charges,47% of Total Billed Charges,17.78,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17.78,103.4,
LACTIC ACID,4018579,CDM,301,RC,83605,HCPCS,Outpatient,,,111.30,111.30,,65.39,58.75,,55.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,65.39,58.75,,55.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,53.88,48.41,,77.96,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.06,100,,3.6,fee Schedule,100% of BCBS fee schedule,13.06,100,,21.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,52.31,47,,75.688,Percent of Total Billed Charges,47% of Total Billed Charges,13.06,100,,21.6,Fee Schedule,100% of BCBS PPO fee schedule,65.39,58.75,,55.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,52.31,47,,75.688,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,52.31,47,,75.688,Percent of Total Billed Charges,47% of Total Billed Charges,9.37,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9.37,65.39,
PREALBUMIN,4018580,CDM,301,RC,84134,HCPCS,Outpatient,,,129.00,129.00,,75.79,58.75,,37.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.79,58.75,,37.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.45,48.41,,27.888,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.83,100,,90.288,fee Schedule,100% of BCBS fee schedule,17.83,100,,113.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,60.63,47,,27.072,Percent of Total Billed Charges,47% of Total Billed Charges,17.83,100,,113.04,Fee Schedule,100% of BCBS PPO fee schedule,75.79,58.75,,37.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,60.63,47,,27.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,60.63,47,,27.072,Percent of Total Billed Charges,47% of Total Billed Charges,11.82,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.82,75.79,
URINE CYTOLOGY,4018581,CDM,301,RC,88112,HCPCS,Outpatient,,,176.00,176.00,,103.4,58.75,,90.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,103.4,58.75,,90.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,85.2,48.41,,14.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,45.01,100,,12.96,fee Schedule,100% of BCBS fee schedule,45.01,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,82.72,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,45.01,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,103.4,58.75,,90.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,82.72,47,,13.912,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,82.72,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,41.11,90,,,Fee Schedule,90% of UHC fee schedule,67.6,115,,22.936,Fee Schedule,115% of CMS OPPS Rate,67.6,115,,15.04,Fee Schedule,115% of CMS OPPS Rate,41.11,103.4,
FREE PSA,4018582,CDM,301,RC,84154,HCPCS,Outpatient,,,41.00,41.00,,24.09,58.75,,98.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.09,58.75,,98.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.85,48.41,,127.8,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.48,100,,22.32,fee Schedule,100% of BCBS fee schedule,22.48,100,,7.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,19.27,47,,124.08,Percent of Total Billed Charges,47% of Total Billed Charges,22.48,100,,7.92,Fee Schedule,100% of BCBS PPO fee schedule,24.09,58.75,,98.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.27,47,,124.08,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,19.27,47,,124.08,Percent of Total Billed Charges,47% of Total Billed Charges,14.9,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14.9,24.09,
TACROLIMUS FK506,4018583,CDM,301,RC,80197,HCPCS,Outpatient,,,179.00,179.00,,105.16,58.75,,18.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,105.16,58.75,,18.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.65,48.41,,92.016,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.79,100,,28.8,fee Schedule,100% of BCBS fee schedule,16.79,100,,25.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,84.13,47,,89.336,Percent of Total Billed Charges,47% of Total Billed Charges,16.79,100,,25.92,Fee Schedule,100% of BCBS PPO fee schedule,105.16,58.75,,18.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,84.13,47,,89.336,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,84.13,47,,89.336,Percent of Total Billed Charges,47% of Total Billed Charges,11.12,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.12,105.16,
PROGESTERONE,4018585,CDM,301,RC,84144,HCPCS,Outpatient,,,100.00,100.00,,58.75,58.75,,96.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.75,58.75,,96.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.41,48.41,,147.992,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.5,100,,3.6,fee Schedule,100% of BCBS fee schedule,25.5,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,47,47,,143.688,Percent of Total Billed Charges,47% of Total Billed Charges,25.5,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,58.75,58.75,,96.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47,47,,143.688,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47,47,,143.688,Percent of Total Billed Charges,47% of Total Billed Charges,16.89,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.89,58.75,
FREE T3,4018586,CDM,301,RC,84481,HCPCS,Outpatient,,,120.00,120.00,,70.5,58.75,,61.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,70.5,58.75,,61.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.09,48.41,,22.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.7,100,,17.28,fee Schedule,100% of BCBS fee schedule,20.7,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,56.4,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,20.7,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,70.5,58.75,,61.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,56.4,47,,21.432,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,56.4,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,13.73,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.73,70.5,
FREE TESTOSTERONE,4018587,CDM,301,RC,84402,HCPCS,Outpatient,,,125.40,125.40,,73.67,58.75,,38.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.67,58.75,,38.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,60.71,48.41,,35.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,31.13,100,,14.4,fee Schedule,100% of BCBS fee schedule,31.13,100,,90.288,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,58.94,47,,34.176,Percent of Total Billed Charges,47% of Total Billed Charges,31.13,100,,90.288,Fee Schedule,100% of BCBS PPO fee schedule,73.67,58.75,,38.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,58.94,47,,34.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,58.94,47,,34.176,Percent of Total Billed Charges,47% of Total Billed Charges,20.63,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20.63,73.67,
FOLATE RED CELL,4018588,CDM,300,RC,82747,HCPCS,Outpatient,,,144.00,144.00,,84.6,58.75,,96.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.6,58.75,,96.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.71,48.41,,66.576,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.18,100,,10.08,fee Schedule,100% of BCBS fee schedule,21.18,100,,12.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,67.68,47,,64.632,Percent of Total Billed Charges,47% of Total Billed Charges,21.18,100,,12.96,Fee Schedule,100% of BCBS PPO fee schedule,84.6,58.75,,96.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,67.68,47,,64.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,67.68,47,,64.632,Percent of Total Billed Charges,47% of Total Billed Charges,14.3,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14.3,84.6,
CREATININE 24 HR URINE,4018589,CDM,307,RC,82570,HCPCS,Outpatient,,,44.00,44.00,,25.85,58.75,,21.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.85,58.75,,21.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.3,48.41,,11.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.33,100,,19.44,fee Schedule,100% of BCBS fee schedule,6.33,100,,22.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,20.68,47,,11.216,Percent of Total Billed Charges,47% of Total Billed Charges,6.33,100,,22.32,Fee Schedule,100% of BCBS PPO fee schedule,25.85,58.75,,21.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,11.216,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,20.68,47,,11.216,Percent of Total Billed Charges,47% of Total Billed Charges,4.19,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.19,25.85,
CA 153,4018590,CDM,300,RC,86300,HCPCS,Outpatient,,,119.00,119.00,,69.91,58.75,,45.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.91,58.75,,45.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.61,48.41,,4.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.44,100,,10.08,fee Schedule,100% of BCBS fee schedule,25.44,100,,28.8,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,55.93,47,,4.36,Percent of Total Billed Charges,47% of Total Billed Charges,25.44,100,,28.8,Fee Schedule,100% of BCBS PPO fee schedule,69.91,58.75,,45.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.93,47,,4.36,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,55.93,47,,4.36,Percent of Total Billed Charges,47% of Total Billed Charges,16.86,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.86,69.91,
HEP C VIRUS ANTIBODY,4018591,CDM,302,RC,86803,HCPCS,Outpatient,,,105.60,105.60,,62.04,58.75,,47.096,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.04,58.75,,47.096,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.12,48.41,,203.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.44,100,,28.8,fee Schedule,100% of BCBS fee schedule,17.44,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,49.63,47,,197.776,Percent of Total Billed Charges,47% of Total Billed Charges,17.44,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,62.04,58.75,,47.096,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.63,47,,197.776,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,49.63,47,,197.776,Percent of Total Billed Charges,47% of Total Billed Charges,11.56,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.56,62.04,
HEP B SURFACE AG,4018592,CDM,302,RC,87340,HCPCS,Outpatient,,,66.00,66.00,,38.78,58.75,,78.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.78,58.75,,78.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.95,48.41,,76.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.63,100,,43.92,fee Schedule,100% of BCBS fee schedule,12.63,100,,17.28,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,31.02,47,,74.448,Percent of Total Billed Charges,47% of Total Billed Charges,12.63,100,,17.28,Fee Schedule,100% of BCBS PPO fee schedule,38.78,58.75,,78.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.02,47,,74.448,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.02,47,,74.448,Percent of Total Billed Charges,47% of Total Billed Charges,8.37,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.37,38.78,
LUTEINIZING HORMONE,4018593,CDM,300,RC,83002,HCPCS,Outpatient,,,96.00,96.00,,56.4,58.75,,28.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,56.4,58.75,,28.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.47,48.41,,103.192,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.63,100,,43.92,fee Schedule,100% of BCBS fee schedule,22.63,100,,14.4,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,45.12,47,,100.184,Percent of Total Billed Charges,47% of Total Billed Charges,22.63,100,,14.4,Fee Schedule,100% of BCBS PPO fee schedule,56.4,58.75,,28.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.12,47,,100.184,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,45.12,47,,100.184,Percent of Total Billed Charges,47% of Total Billed Charges,15,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15,56.4,
FOLLICLE STIM HORMONE,4018594,CDM,301,RC,83001,HCPCS,Outpatient,,,90.00,90.00,,52.88,58.75,,92.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,52.88,58.75,,92.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,43.57,48.41,,68.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.72,100,,16.56,fee Schedule,100% of BCBS fee schedule,22.72,100,,10.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,42.3,47,,66.216,Percent of Total Billed Charges,47% of Total Billed Charges,22.72,100,,10.08,Fee Schedule,100% of BCBS PPO fee schedule,52.88,58.75,,92.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,42.3,47,,66.216,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,42.3,47,,66.216,Percent of Total Billed Charges,47% of Total Billed Charges,15.05,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15.05,52.88,
CORTISOL LEVEL,4018595,CDM,301,RC,82533,HCPCS,Outpatient,,,122.00,122.00,,71.68,58.75,,98.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,71.68,58.75,,98.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,59.06,48.41,,75.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.92,100,,43.92,fee Schedule,100% of BCBS fee schedule,19.92,100,,19.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,57.34,47,,73.656,Percent of Total Billed Charges,47% of Total Billed Charges,19.92,100,,19.44,Fee Schedule,100% of BCBS PPO fee schedule,71.68,58.75,,98.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,57.34,47,,73.656,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,57.34,47,,73.656,Percent of Total Billed Charges,47% of Total Billed Charges,13.2,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.2,71.68,
URIC ACID 24 HR URINE,4018596,CDM,307,RC,84560,HCPCS,Outpatient,,,36.30,36.30,,21.33,58.75,,16.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.33,58.75,,16.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.57,48.41,,19.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.8,100,,16.56,fee Schedule,100% of BCBS fee schedule,5.8,100,,10.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,17.06,47,,18.832,Percent of Total Billed Charges,47% of Total Billed Charges,5.8,100,,10.08,Fee Schedule,100% of BCBS PPO fee schedule,21.33,58.75,,16.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.06,47,,18.832,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.06,47,,18.832,Percent of Total Billed Charges,47% of Total Billed Charges,4.11,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.11,21.33,
CALCIUM 24 HR URINE,4018597,CDM,307,RC,82340,HCPCS,Outpatient,,,36.30,36.30,,21.33,58.75,,125.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.33,58.75,,125.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.57,48.41,,34.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.37,100,,43.92,fee Schedule,100% of BCBS fee schedule,7.37,100,,28.8,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,17.06,47,,33.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.37,100,,28.8,Fee Schedule,100% of BCBS PPO fee schedule,21.33,58.75,,125.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.06,47,,33.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.06,47,,33.392,Percent of Total Billed Charges,47% of Total Billed Charges,4.89,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.89,21.33,
SODIUM 24 HR URINE,4018598,CDM,307,RC,84300,HCPCS,Outpatient,,,72.60,72.60,,42.65,58.75,,152.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.65,58.75,,152.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.15,48.41,,55.888,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.94,100,,1.44,fee Schedule,100% of BCBS fee schedule,5.94,100,,43.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,34.12,47,,54.256,Percent of Total Billed Charges,47% of Total Billed Charges,5.94,100,,43.92,Fee Schedule,100% of BCBS PPO fee schedule,42.65,58.75,,152.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,34.12,47,,54.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,34.12,47,,54.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.1,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.1,42.65,
VITAMIN B1 THIAMINE,4018599,CDM,301,RC,84425,HCPCS,Outpatient,,,117.60,117.60,,69.09,58.75,,14.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.09,58.75,,14.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,56.93,48.41,,23.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.95,100,,3.96,fee Schedule,100% of BCBS fee schedule,25.95,100,,43.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,55.27,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,25.95,100,,43.92,Fee Schedule,100% of BCBS PPO fee schedule,69.09,58.75,,14.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.27,47,,22.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,55.27,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,17.2,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17.2,69.09,
INSULIN,4018600,CDM,301,RC,83525,HCPCS,Outpatient,,,80.00,80.00,,47,58.75,,16.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,47,58.75,,16.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.73,48.41,,31.368,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.97,100,,3.6,fee Schedule,100% of BCBS fee schedule,13.97,100,,16.56,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,37.6,47,,30.456,Percent of Total Billed Charges,47% of Total Billed Charges,13.97,100,,16.56,Fee Schedule,100% of BCBS PPO fee schedule,47,58.75,,16.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.6,47,,30.456,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,37.6,47,,30.456,Percent of Total Billed Charges,47% of Total Billed Charges,9.26,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9.26,47,
"PROTEIN ELECTROPHORESIS, URINE",4018601,CDM,301,RC,84166,HCPCS,Outpatient,,,193.00,193.00,,113.39,58.75,,61.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,113.39,58.75,,61.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,93.43,48.41,,41.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.79,100,,23.76,fee Schedule,100% of BCBS fee schedule,21.79,100,,43.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,90.71,47,,39.928,Percent of Total Billed Charges,47% of Total Billed Charges,21.79,100,,43.92,Fee Schedule,100% of BCBS PPO fee schedule,113.39,58.75,,61.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,90.71,47,,39.928,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,90.71,47,,39.928,Percent of Total Billed Charges,47% of Total Billed Charges,14.45,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14.45,113.39,
VITAMIN B6,4018602,CDM,301,RC,84207,HCPCS,Outpatient,,,209.00,209.00,,122.79,58.75,,52.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,122.79,58.75,,52.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,101.18,48.41,,58.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,34.34,100,,3.6,fee Schedule,100% of BCBS fee schedule,34.34,100,,16.56,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,98.23,47,,56.944,Percent of Total Billed Charges,47% of Total Billed Charges,34.34,100,,16.56,Fee Schedule,100% of BCBS PPO fee schedule,122.79,58.75,,52.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,98.23,47,,56.944,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,98.23,47,,56.944,Percent of Total Billed Charges,47% of Total Billed Charges,22.76,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22.76,122.79,
AMIKACIN,4018603,CDM,301,RC,80150,HCPCS,Outpatient,,,38.41,38.41,,22.57,58.75,,49.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.57,58.75,,49.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.59,48.41,,3.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.43,100,,15.84,fee Schedule,100% of BCBS fee schedule,18.43,100,,43.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,18.05,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,18.43,100,,43.92,Fee Schedule,100% of BCBS PPO fee schedule,22.57,58.75,,49.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.05,47,,3.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.05,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,12.21,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12.21,22.57,
"ACTH, PLASMA",4018604,CDM,301,RC,82024,HCPCS,Outpatient,,,206.10,206.10,,121.08,58.75,,10.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,121.08,58.75,,10.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,99.77,48.41,,84.464,Percent of Total Billed Charges,48.41% of Total Billed Charges,47.2,100,,5.04,fee Schedule,100% of BCBS fee schedule,47.2,100,,1.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,96.87,47,,82.008,Percent of Total Billed Charges,47% of Total Billed Charges,47.2,100,,1.44,Fee Schedule,100% of BCBS PPO fee schedule,121.08,58.75,,10.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,96.87,47,,82.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,96.87,47,,82.008,Percent of Total Billed Charges,47% of Total Billed Charges,31.28,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31.28,121.08,
ACTIN (SMOOTH MUSCLE) ANTIBODY,4018605,CDM,302,RC,83516,HCPCS,Outpatient,,,131.00,131.00,,76.96,58.75,,110.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.96,58.75,,110.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,63.42,48.41,,34.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.09,100,,8.64,fee Schedule,100% of BCBS fee schedule,14.09,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,61.57,47,,33.392,Percent of Total Billed Charges,47% of Total Billed Charges,14.09,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,76.96,58.75,,110.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,61.57,47,,33.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,61.57,47,,33.392,Percent of Total Billed Charges,47% of Total Billed Charges,9.34,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9.34,76.96,
ALDOLASE,4018606,CDM,301,RC,82085,HCPCS,Outpatient,,,82.80,82.80,,48.65,58.75,,100.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.65,58.75,,100.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.08,48.41,,25.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.87,100,,3.6,fee Schedule,100% of BCBS fee schedule,11.87,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,38.92,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,11.87,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,48.65,58.75,,100.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.92,47,,24.816,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,38.92,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,7.87,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.87,48.65,
"ALDOSTERONE, SERUM",4018607,CDM,301,RC,82088,HCPCS,Outpatient,,,204.75,204.75,,120.29,58.75,,52.736,Percent of Total Billed Charges,58.75% of Total Billed Charges,120.29,58.75,,52.736,Percent of Total Billed Charges,58.75% of Total Billed Charges,99.12,48.41,,4.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,49.81,100,,3.6,fee Schedule,100% of BCBS fee schedule,49.81,100,,23.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,96.23,47,,4.448,Percent of Total Billed Charges,47% of Total Billed Charges,49.81,100,,23.76,Fee Schedule,100% of BCBS PPO fee schedule,120.29,58.75,,52.736,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,96.23,47,,4.448,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,96.23,47,,4.448,Percent of Total Billed Charges,47% of Total Billed Charges,33.01,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,33.01,120.29,
ANAEROBIC CULTURE,4018608,CDM,306,RC,87075,HCPCS,Outpatient,,,45.55,45.55,,26.76,58.75,,52.736,Percent of Total Billed Charges,58.75% of Total Billed Charges,26.76,58.75,,52.736,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.05,48.41,,20.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.57,100,,43.92,fee Schedule,100% of BCBS fee schedule,11.57,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,21.41,47,,19.832,Percent of Total Billed Charges,47% of Total Billed Charges,11.57,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,26.76,58.75,,52.736,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.41,47,,19.832,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,21.41,47,,19.832,Percent of Total Billed Charges,47% of Total Billed Charges,7.67,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.67,26.76,
ANGIOTENSIN-CONVERTING ENZYME,4018609,CDM,301,RC,82164,HCPCS,Outpatient,,,97.50,97.50,,57.28,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.28,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.2,48.41,,84.944,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.84,100,,84.24,fee Schedule,100% of BCBS fee schedule,17.84,100,,15.84,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,45.83,47,,82.472,Percent of Total Billed Charges,47% of Total Billed Charges,17.84,100,,15.84,Fee Schedule,100% of BCBS PPO fee schedule,57.28,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.83,47,,82.472,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,45.83,47,,82.472,Percent of Total Billed Charges,47% of Total Billed Charges,11.83,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.83,57.28,
CCP ANTIBODIES IGG/IGA,4018610,CDM,302,RC,86200,HCPCS,Outpatient,,,100.20,100.20,,58.87,58.75,,84.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.87,58.75,,84.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.51,48.41,,37.176,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.83,100,,3.6,fee Schedule,100% of BCBS fee schedule,15.83,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,47.09,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,15.83,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,58.87,58.75,,84.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47.09,47,,36.096,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47.09,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,10.49,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.49,58.87,
DHEA-SULFATE,4018611,CDM,301,RC,82627,HCPCS,Outpatient,,,166.00,166.00,,97.53,58.75,,90.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,97.53,58.75,,90.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,80.36,48.41,,43.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,27.18,100,,5.04,fee Schedule,100% of BCBS fee schedule,27.18,100,,8.64,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,78.02,47,,42.304,Percent of Total Billed Charges,47% of Total Billed Charges,27.18,100,,8.64,Fee Schedule,100% of BCBS PPO fee schedule,97.53,58.75,,90.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,78.02,47,,42.304,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,78.02,47,,42.304,Percent of Total Billed Charges,47% of Total Billed Charges,18.01,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18.01,97.53,
ESTRADIOL,4018612,CDM,301,RC,82670,HCPCS,Outpatient,,,60.09,60.09,,35.3,58.75,,7.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.3,58.75,,7.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.09,48.41,,45.912,Percent of Total Billed Charges,48.41% of Total Billed Charges,34.14,100,,10.08,fee Schedule,100% of BCBS fee schedule,34.14,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,28.24,47,,44.576,Percent of Total Billed Charges,47% of Total Billed Charges,34.14,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,35.3,58.75,,7.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.24,47,,44.576,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.24,47,,44.576,Percent of Total Billed Charges,47% of Total Billed Charges,22.64,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22.64,35.3,
"ESTRONE, SERUM",4018613,CDM,301,RC,82679,HCPCS,Outpatient,,,195.90,195.90,,115.09,58.75,,18.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,115.09,58.75,,18.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,94.84,48.41,,50.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.5,100,,5.04,fee Schedule,100% of BCBS fee schedule,30.5,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,92.07,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,30.5,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,115.09,58.75,,18.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,92.07,47,,48.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,92.07,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,20.21,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20.21,115.09,
FACTOR V ACTIVITY,4018614,CDM,300,RC,85220,HCPCS,Outpatient,,,210.00,210.00,,123.38,58.75,,21.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,123.38,58.75,,21.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,101.66,48.41,,19.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.57,100,,5.04,fee Schedule,100% of BCBS fee schedule,21.57,100,,43.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,98.7,47,,19.008,Percent of Total Billed Charges,47% of Total Billed Charges,21.57,100,,43.92,Fee Schedule,100% of BCBS PPO fee schedule,123.38,58.75,,21.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,98.7,47,,19.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,98.7,47,,19.008,Percent of Total Billed Charges,47% of Total Billed Charges,14.3,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14.3,123.38,
"FECAL FAT, QUALITATIVE",4018615,CDM,306,RC,82705,HCPCS,Outpatient,,,34.68,34.68,,20.37,58.75,,25.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.37,58.75,,25.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.79,48.41,,63.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.23,100,,45.144,fee Schedule,100% of BCBS fee schedule,6.23,100,,84.24,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,16.3,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,6.23,100,,84.24,Fee Schedule,100% of BCBS PPO fee schedule,20.37,58.75,,25.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.3,47,,62.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.3,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,4.13,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.13,20.37,
H PYLORI STOOL AG ELA,4018616,CDM,306,RC,87338,HCPCS,Outpatient,,,266.80,266.80,,156.75,58.75,,64.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,156.75,58.75,,64.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,129.16,48.41,,51.12,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.58,100,,8.712,fee Schedule,100% of BCBS fee schedule,17.58,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,125.4,47,,49.632,Percent of Total Billed Charges,47% of Total Billed Charges,17.58,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,156.75,58.75,,64.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,125.4,47,,49.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,125.4,47,,49.632,Percent of Total Billed Charges,47% of Total Billed Charges,11.65,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.65,156.75,
HUMAN GRANULOCYTIC EHRLISH HGE,4018617,CDM,302,RC,86666,HCPCS,Outpatient,,,324.00,324.00,,190.35,58.75,,47.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,190.35,58.75,,47.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,156.85,48.41,,81.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.44,100,,12.96,fee Schedule,100% of BCBS fee schedule,12.44,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,152.28,47,,78.96,Percent of Total Billed Charges,47% of Total Billed Charges,12.44,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,190.35,58.75,,47.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,152.28,47,,78.96,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,152.28,47,,78.96,Percent of Total Billed Charges,47% of Total Billed Charges,8.24,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.24,190.35,
LDL CHOLESTEROL (DIRECT),4018618,CDM,301,RC,83721,HCPCS,Outpatient,,,29.81,29.81,,17.51,58.75,,17.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.51,58.75,,17.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.43,48.41,,50.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.66,100,,36.72,fee Schedule,100% of BCBS fee schedule,11.66,100,,10.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,14.01,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,11.66,100,,10.08,Fee Schedule,100% of BCBS PPO fee schedule,17.51,58.75,,17.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.01,47,,48.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.01,47,,48.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.51,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.51,17.51,
MICROALBUMIN 24 HR URINE,4018619,CDM,307,RC,82043,HCPCS,Outpatient,,,34.16,34.16,,20.07,58.75,,39.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.07,58.75,,39.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.54,48.41,,32.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.06,100,,4.32,fee Schedule,100% of BCBS fee schedule,7.06,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,16.06,47,,31.192,Percent of Total Billed Charges,47% of Total Billed Charges,7.06,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,20.07,58.75,,39.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.06,47,,31.192,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.06,47,,31.192,Percent of Total Billed Charges,47% of Total Billed Charges,4.68,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.68,20.07,
MITOCHONDRIAL (M2) ANTIBODY,4018620,CDM,302,RC,83516,HCPCS,Outpatient,,,131.00,131.00,,76.96,58.75,,16.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.96,58.75,,16.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,63.42,48.41,,38.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.09,100,,16.56,fee Schedule,100% of BCBS fee schedule,14.09,100,,5.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,61.57,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,14.09,100,,5.04,Fee Schedule,100% of BCBS PPO fee schedule,76.96,58.75,,16.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,61.57,47,,37.6,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,61.57,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,9.34,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9.34,76.96,
MUMPS ANTIBODIES IGM,4018621,CDM,302,RC,86735,HCPCS,Outpatient,,,112.50,112.50,,66.09,58.75,,72.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.09,58.75,,72.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,54.46,48.41,,18.976,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.95,100,,18.72,fee Schedule,100% of BCBS fee schedule,15.95,100,,45.144,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,52.88,47,,18.424,Percent of Total Billed Charges,47% of Total Billed Charges,15.95,100,,45.144,Fee Schedule,100% of BCBS PPO fee schedule,66.09,58.75,,72.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,52.88,47,,18.424,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,52.88,47,,18.424,Percent of Total Billed Charges,47% of Total Billed Charges,10.58,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.58,66.09,
PRIMIDONE,4018622,CDM,301,RC,80188,HCPCS,Outpatient,,,105.00,105.00,,61.69,58.75,,94.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.69,58.75,,94.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.83,48.41,,8.76,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.28,100,,3.6,fee Schedule,100% of BCBS fee schedule,20.28,100,,8.712,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,49.35,47,,8.504,Percent of Total Billed Charges,47% of Total Billed Charges,20.28,100,,8.712,Fee Schedule,100% of BCBS PPO fee schedule,61.69,58.75,,94.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.35,47,,8.504,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,49.35,47,,8.504,Percent of Total Billed Charges,47% of Total Billed Charges,13.44,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.44,61.69,
"PROTEIN, TOTAL URINE",4018623,CDM,307,RC,84156,HCPCS,Outpatient,,,22.48,22.48,,13.21,58.75,,33.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.21,58.75,,33.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.88,48.41,,96.664,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.48,100,,25.92,fee Schedule,100% of BCBS fee schedule,4.48,100,,12.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,10.57,47,,93.848,Percent of Total Billed Charges,47% of Total Billed Charges,4.48,100,,12.96,Fee Schedule,100% of BCBS PPO fee schedule,13.21,58.75,,33.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.57,47,,93.848,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.57,47,,93.848,Percent of Total Billed Charges,47% of Total Billed Charges,2.97,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.97,13.21,
REVERSE T3 SERUM,4018624,CDM,301,RC,84482,HCPCS,Outpatient,,,235.80,235.80,,138.53,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,138.53,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,114.15,48.41,,96.664,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.26,100,,27.36,fee Schedule,100% of BCBS fee schedule,19.26,100,,36.72,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,110.83,47,,93.848,Percent of Total Billed Charges,47% of Total Billed Charges,19.26,100,,36.72,Fee Schedule,100% of BCBS PPO fee schedule,138.53,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,110.83,47,,93.848,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,110.83,47,,93.848,Percent of Total Billed Charges,47% of Total Billed Charges,12.76,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12.76,138.53,
RISPERIDONE (RISPERDAL SERUM,4018625,CDM,301,RC,80342,HCPCS,Outpatient,,,213.90,213.90,,125.67,58.75,,155.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,125.67,58.75,,155.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,103.55,48.41,,147.792,Percent of Total Billed Charges,48.41% of Total Billed Charges,33.33,100,,46.08,fee Schedule,100% of BCBS fee schedule,33.33,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,100.53,47,,143.488,Percent of Total Billed Charges,47% of Total Billed Charges,33.33,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,125.67,58.75,,155.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,100.53,47,,143.488,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,100.53,47,,143.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,33.33,125.67,
SEX HORMONE BINDING GLOBULIN,4018626,CDM,301,RC,84270,HCPCS,Outpatient,,,112.20,112.20,,65.92,58.75,,111.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,65.92,58.75,,111.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,54.32,48.41,,147.792,Percent of Total Billed Charges,48.41% of Total Billed Charges,26.57,100,,7.2,fee Schedule,100% of BCBS fee schedule,26.57,100,,16.56,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,52.73,47,,143.488,Percent of Total Billed Charges,47% of Total Billed Charges,26.57,100,,16.56,Fee Schedule,100% of BCBS PPO fee schedule,65.92,58.75,,111.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,52.73,47,,143.488,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,52.73,47,,143.488,Percent of Total Billed Charges,47% of Total Billed Charges,17.6,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17.6,65.92,
TETANUS ANTITOXOID IGG AB,4018627,CDM,302,RC,86317,HCPCS,Outpatient,,,112.20,112.20,,65.92,58.75,,179.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,65.92,58.75,,179.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,54.32,48.41,,13.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.32,100,,788.4,fee Schedule,100% of BCBS fee schedule,18.32,100,,18.72,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,52.73,47,,13.192,Percent of Total Billed Charges,47% of Total Billed Charges,18.32,100,,18.72,Fee Schedule,100% of BCBS PPO fee schedule,65.92,58.75,,179.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,52.73,47,,13.192,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,52.73,47,,13.192,Percent of Total Billed Charges,47% of Total Billed Charges,12.14,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12.14,65.92,
THYROID PEROXIDASE (TPO) AB,4018628,CDM,302,RC,86376,HCPCS,Outpatient,,,30.00,30.00,,17.63,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.63,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.52,48.41,,13.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.79,100,,15.84,fee Schedule,100% of BCBS fee schedule,17.79,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,14.1,47,,13.192,Percent of Total Billed Charges,47% of Total Billed Charges,17.79,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,17.63,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,13.192,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.1,47,,13.192,Percent of Total Billed Charges,47% of Total Billed Charges,11.79,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.79,17.79,
TOPIRAMATE (TOPAMAX),4018629,CDM,301,RC,80201,HCPCS,Outpatient,,,179.00,179.00,,105.16,58.75,,42.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,105.16,58.75,,42.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.65,48.41,,13.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.56,100,,23.04,fee Schedule,100% of BCBS fee schedule,14.56,100,,25.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,84.13,47,,13.192,Percent of Total Billed Charges,47% of Total Billed Charges,14.56,100,,25.92,Fee Schedule,100% of BCBS PPO fee schedule,105.16,58.75,,42.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,84.13,47,,13.192,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,84.13,47,,13.192,Percent of Total Billed Charges,47% of Total Billed Charges,9.66,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9.66,105.16,
VWF ACTIVITY,4018631,CDM,300,RC,85245,HCPCS,Outpatient,,,192.00,192.00,,112.8,58.75,,80.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,112.8,58.75,,80.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,92.95,48.41,,13.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.04,100,,17.28,fee Schedule,100% of BCBS fee schedule,28.04,100,,27.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,90.24,47,,13.192,Percent of Total Billed Charges,47% of Total Billed Charges,28.04,100,,27.36,Fee Schedule,100% of BCBS PPO fee schedule,112.8,58.75,,80.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,90.24,47,,13.192,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,90.24,47,,13.192,Percent of Total Billed Charges,47% of Total Billed Charges,18.59,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18.59,112.8,
WBC STOOL,4018632,CDM,306,RC,89055,HCPCS,Outpatient,,,15.84,15.84,,9.31,58.75,,14.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.31,58.75,,14.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.67,48.41,,51.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.23,100,,19.44,fee Schedule,100% of BCBS fee schedule,5.23,100,,46.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,7.44,47,,50.328,Percent of Total Billed Charges,47% of Total Billed Charges,5.23,100,,46.08,Fee Schedule,100% of BCBS PPO fee schedule,9.31,58.75,,14.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.44,47,,50.328,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.44,47,,50.328,Percent of Total Billed Charges,47% of Total Billed Charges,3.46,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.46,9.31,
EB VIRUS EARLY ANTIGEN (EA),4018634,CDM,302,RC,86663,HCPCS,Outpatient,,,38.70,38.70,,22.74,58.75,,5.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.74,58.75,,5.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.73,48.41,,105.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.04,100,,15.12,fee Schedule,100% of BCBS fee schedule,16.04,100,,7.2,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,18.19,47,,102.272,Percent of Total Billed Charges,47% of Total Billed Charges,16.04,100,,7.2,Fee Schedule,100% of BCBS PPO fee schedule,22.74,58.75,,5.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.19,47,,102.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.19,47,,102.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.63,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.63,22.74,
EB VIRUS NUCLEAR ANTIGEN,4018635,CDM,302,RC,86664,HCPCS,Outpatient,,,45.60,45.60,,26.79,58.75,,247.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,26.79,58.75,,247.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.07,48.41,,19.368,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.69,100,,36,fee Schedule,100% of BCBS fee schedule,18.69,100,,788.4,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,21.43,47,,18.8,Percent of Total Billed Charges,47% of Total Billed Charges,18.69,100,,788.4,Fee Schedule,100% of BCBS PPO fee schedule,26.79,58.75,,247.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.43,47,,18.8,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,21.43,47,,18.8,Percent of Total Billed Charges,47% of Total Billed Charges,12.38,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12.38,26.79,
EB VIRUS CAPSID (VCA),4018636,CDM,302,RC,86665,HCPCS,Outpatient,,,53.90,53.90,,31.67,58.75,,93.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.67,58.75,,93.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,26.09,48.41,,137.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.18,100,,17.28,fee Schedule,100% of BCBS fee schedule,22.18,100,,15.84,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,25.33,47,,133.136,Percent of Total Billed Charges,47% of Total Billed Charges,22.18,100,,15.84,Fee Schedule,100% of BCBS PPO fee schedule,31.67,58.75,,93.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,25.33,47,,133.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,25.33,47,,133.136,Percent of Total Billed Charges,47% of Total Billed Charges,14.7,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14.7,31.67,
EBV ACUTE INFECTION ANTIBODIES,4018637,CDM,302,RC,,,Outpatient,,,138.20,138.20,,81.19,58.75,,125.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,81.19,58.75,,125.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.9,48.41,,135.472,Percent of Total Billed Charges,48.41% of Total Billed Charges,124.38,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,124.38,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,64.95,47,,131.528,Percent of Total Billed Charges,47% of Total Billed Charges,124.38,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,81.19,58.75,,125.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,64.95,47,,131.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,64.95,47,,131.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,64.95,124.38,
"CORTISOL, AM",4018638,CDM,301,RC,82533,HCPCS,Outpatient,,,100.80,100.80,,59.22,58.75,,82.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,59.22,58.75,,82.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.8,48.41,,106.888,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.92,100,,13.68,fee Schedule,100% of BCBS fee schedule,19.92,100,,17.28,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,47.38,47,,103.776,Percent of Total Billed Charges,47% of Total Billed Charges,19.92,100,,17.28,Fee Schedule,100% of BCBS PPO fee schedule,59.22,58.75,,82.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47.38,47,,103.776,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47.38,47,,103.776,Percent of Total Billed Charges,47% of Total Billed Charges,13.2,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.2,59.22,
"MICROALBUMIN, RANDOM URINE",4018639,CDM,307,RC,82043,HCPCS,Outpatient,,,37.58,37.58,,22.08,58.75,,92.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.08,58.75,,92.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.19,48.41,,180.472,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.06,100,,19.44,fee Schedule,100% of BCBS fee schedule,7.06,100,,19.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,17.66,47,,175.216,Percent of Total Billed Charges,47% of Total Billed Charges,7.06,100,,19.44,Fee Schedule,100% of BCBS PPO fee schedule,22.08,58.75,,92.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.66,47,,175.216,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.66,47,,175.216,Percent of Total Billed Charges,47% of Total Billed Charges,4.68,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.68,22.08,
HEPATITUS B E ANTIGEN,4018640,CDM,302,RC,87350,HCPCS,Outpatient,,,84.30,84.30,,49.53,58.75,,23.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.53,58.75,,23.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.81,48.41,,126.192,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.09,100,,13.68,fee Schedule,100% of BCBS fee schedule,14.09,100,,15.12,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,39.62,47,,122.512,Percent of Total Billed Charges,47% of Total Billed Charges,14.09,100,,15.12,Fee Schedule,100% of BCBS PPO fee schedule,49.53,58.75,,23.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,39.62,47,,122.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,39.62,47,,122.512,Percent of Total Billed Charges,47% of Total Billed Charges,9.34,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9.34,49.53,
HEPATITUS B CORE AB,4018641,CDM,302,RC,86704,HCPCS,Outpatient,,,35.04,35.04,,20.59,58.75,,41.736,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.59,58.75,,41.736,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.96,48.41,,39.504,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.73,100,,20.16,fee Schedule,100% of BCBS fee schedule,14.73,100,,36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,16.47,47,,38.352,Percent of Total Billed Charges,47% of Total Billed Charges,14.73,100,,36,Fee Schedule,100% of BCBS PPO fee schedule,20.59,58.75,,41.736,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.47,47,,38.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.47,47,,38.352,Percent of Total Billed Charges,47% of Total Billed Charges,9.77,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9.77,20.59,
P CARINII PNEUMONIA STAIN,4018642,CDM,306,RC,88312,HCPCS,Outpatient,,,154.50,154.50,,90.77,58.75,,67.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,90.77,58.75,,67.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.79,48.41,,63.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,45.01,100,,43.92,fee Schedule,100% of BCBS fee schedule,45.01,100,,17.28,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,72.62,47,,61.416,Percent of Total Billed Charges,47% of Total Billed Charges,45.01,100,,17.28,Fee Schedule,100% of BCBS PPO fee schedule,90.77,58.75,,67.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,72.62,47,,61.416,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,72.62,47,,61.416,Percent of Total Billed Charges,47% of Total Billed Charges,41.11,90,,,Fee Schedule,90% of UHC fee schedule,109.6,115,,411.72,Fee Schedule,115% of CMS OPPS Rate,109.6,115,,8.272,Fee Schedule,115% of CMS OPPS Rate,41.11,109.6,
"CITRIC ACID,CITRATE,URINE 24HR",4018643,CDM,307,RC,82507,HCPCS,Outpatient,,,201.30,201.30,,118.26,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,118.26,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,97.45,48.41,,34.08,Percent of Total Billed Charges,48.41% of Total Billed Charges,33.98,100,,13.68,fee Schedule,100% of BCBS fee schedule,33.98,100,,13.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,94.61,47,,33.088,Percent of Total Billed Charges,47% of Total Billed Charges,33.98,100,,13.68,Fee Schedule,100% of BCBS PPO fee schedule,118.26,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,94.61,47,,33.088,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,94.61,47,,33.088,Percent of Total Billed Charges,47% of Total Billed Charges,22.52,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22.52,118.26,
"CRP, CARDIO",4018644,CDM,300,RC,86141,HCPCS,Outpatient,,,72.00,72.00,,42.3,58.75,,38.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.3,58.75,,38.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.86,48.41,,55.888,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.83,100,,21.6,fee Schedule,100% of BCBS fee schedule,15.83,100,,13.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,33.84,47,,54.256,Percent of Total Billed Charges,47% of Total Billed Charges,15.83,100,,13.68,Fee Schedule,100% of BCBS PPO fee schedule,42.3,58.75,,38.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.84,47,,54.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,33.84,47,,54.256,Percent of Total Billed Charges,47% of Total Billed Charges,10.49,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.49,42.3,
"CREATININE, URINE",4018645,CDM,307,RC,82570,HCPCS,Outpatient,,,37.00,37.00,,21.74,58.75,,49.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.74,58.75,,49.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.91,48.41,,54.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.33,100,,15.048,fee Schedule,100% of BCBS fee schedule,6.33,100,,19.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,17.39,47,,53.056,Percent of Total Billed Charges,47% of Total Billed Charges,6.33,100,,19.44,Fee Schedule,100% of BCBS PPO fee schedule,21.74,58.75,,49.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.39,47,,53.056,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.39,47,,53.056,Percent of Total Billed Charges,47% of Total Billed Charges,4.19,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.19,21.74,
FACTOR V LEIDEN MUTATION,4018646,CDM,300,RC,81241,HCPCS,Outpatient,,,330.00,330.00,,193.88,58.75,,71.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,193.88,58.75,,71.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,159.75,48.41,,22.464,Percent of Total Billed Charges,48.41% of Total Billed Charges,77.33,100,,15.12,fee Schedule,100% of BCBS fee schedule,77.33,100,,13.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,155.1,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,77.33,100,,13.68,Fee Schedule,100% of BCBS PPO fee schedule,193.88,58.75,,71.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,155.1,47,,21.808,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,155.1,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,59.43,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,59.43,193.88,
CHROMOGRANIN A,4018648,CDM,300,RC,86316,HCPCS,Outpatient,,,237.60,237.60,,139.59,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,139.59,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,115.02,48.41,,58.576,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.44,100,,13.68,fee Schedule,100% of BCBS fee schedule,25.44,100,,20.16,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,111.67,47,,56.872,Percent of Total Billed Charges,47% of Total Billed Charges,25.44,100,,20.16,Fee Schedule,100% of BCBS PPO fee schedule,139.59,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,111.67,47,,56.872,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,111.67,47,,56.872,Percent of Total Billed Charges,47% of Total Billed Charges,16.86,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.86,139.59,
SERUM DRUG SCREEN,4018650,CDM,301,RC,80307,HCPCS,Outpatient,,,382.14,382.14,,224.51,58.75,,102.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,224.51,58.75,,102.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,184.99,48.41,,63.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,71.12,100,,15.048,fee Schedule,100% of BCBS fee schedule,71.12,100,,43.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,179.61,47,,61.288,Percent of Total Billed Charges,47% of Total Billed Charges,71.12,100,,43.92,Fee Schedule,100% of BCBS PPO fee schedule,224.51,58.75,,102.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,179.61,47,,61.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,179.61,47,,61.288,Percent of Total Billed Charges,47% of Total Billed Charges,50.34,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50.34,224.51,
LEVETIRACETAM (KEPPRA),4018651,CDM,301,RC,80177,HCPCS,Outpatient,,,57.00,57.00,,33.49,58.75,,41.736,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.49,58.75,,41.736,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.59,48.41,,7.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.2,100,,13.68,fee Schedule,100% of BCBS fee schedule,16.2,100,,13.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,26.79,47,,7.504,Percent of Total Billed Charges,47% of Total Billed Charges,16.2,100,,13.68,Fee Schedule,100% of BCBS PPO fee schedule,33.49,58.75,,41.736,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,7.504,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.79,47,,7.504,Percent of Total Billed Charges,47% of Total Billed Charges,10.74,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.74,33.49,
VITAMIN C,4018652,CDM,301,RC,82180,HCPCS,Outpatient,,,90.90,90.90,,53.4,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,53.4,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,44,48.41,,52.824,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.08,100,,6.48,fee Schedule,100% of BCBS fee schedule,12.08,100,,21.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,42.72,47,,51.288,Percent of Total Billed Charges,47% of Total Billed Charges,12.08,100,,21.6,Fee Schedule,100% of BCBS PPO fee schedule,53.4,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,42.72,47,,51.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,42.72,47,,51.288,Percent of Total Billed Charges,47% of Total Billed Charges,8.01,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.01,53.4,
HOMOCYSTEINE,4018653,CDM,301,RC,83090,HCPCS,Outpatient,,,171.90,171.90,,100.99,58.75,,5.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,100.99,58.75,,5.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,83.22,48.41,,63.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.61,100,,8.64,fee Schedule,100% of BCBS fee schedule,20.61,100,,15.048,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,80.79,47,,61.416,Percent of Total Billed Charges,47% of Total Billed Charges,20.61,100,,15.048,Fee Schedule,100% of BCBS PPO fee schedule,100.99,58.75,,5.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,80.79,47,,61.416,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,80.79,47,,61.416,Percent of Total Billed Charges,47% of Total Billed Charges,14.52,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14.52,100.99,
ANTISTREPTOLYSIN O AB,4018654,CDM,302,RC,86060,HCPCS,Outpatient,,,29.84,29.84,,17.53,58.75,,24.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.53,58.75,,24.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.45,48.41,,15.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.92,100,,3.96,fee Schedule,100% of BCBS fee schedule,8.92,100,,15.12,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,14.02,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,8.92,100,,15.12,Fee Schedule,100% of BCBS PPO fee schedule,17.53,58.75,,24.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.02,47,,15.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.02,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,5.91,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.91,17.53,
"PHOSPHORUS, 24 HR URINE",4018655,CDM,307,RC,84105,HCPCS,Outpatient,,,11.59,11.59,,6.81,58.75,,103.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.81,58.75,,103.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.61,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.36,100,,13.68,fee Schedule,100% of BCBS fee schedule,6.36,100,,13.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,5.45,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,6.36,100,,13.68,Fee Schedule,100% of BCBS PPO fee schedule,6.81,58.75,,103.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.45,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.45,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,4.68,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.68,6.81,
BORDETELLA PERTUSSIS ANTIBODIE,4018656,CDM,302,RC,86615,HCPCS,Outpatient,,,526.00,526.00,,309.03,58.75,,45.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,309.03,58.75,,45.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,254.64,48.41,,11.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.12,100,,18,fee Schedule,100% of BCBS fee schedule,16.12,100,,15.048,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,247.22,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,16.12,100,,15.048,Fee Schedule,100% of BCBS PPO fee schedule,309.03,58.75,,45.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,247.22,47,,11.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,247.22,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,10.68,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.68,309.03,
CATECHOLAMINES 24 HR URINE,4018657,CDM,307,RC,82384,HCPCS,Outpatient,,,198.00,198.00,,116.33,58.75,,52.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,116.33,58.75,,52.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,95.85,48.41,,13.168,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.87,100,,13.68,fee Schedule,100% of BCBS fee schedule,30.87,100,,13.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,93.06,47,,12.784,Percent of Total Billed Charges,47% of Total Billed Charges,30.87,100,,13.68,Fee Schedule,100% of BCBS PPO fee schedule,116.33,58.75,,52.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,93.06,47,,12.784,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,93.06,47,,12.784,Percent of Total Billed Charges,47% of Total Billed Charges,20.46,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20.46,116.33,
METANEPHRINES 24 HR URINE,4018658,CDM,307,RC,83835,HCPCS,Outpatient,,,266.45,266.45,,156.54,58.75,,55.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,156.54,58.75,,55.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,128.99,48.41,,9.296,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.7,100,,13.68,fee Schedule,100% of BCBS fee schedule,20.7,100,,6.48,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,125.23,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,20.7,100,,6.48,Fee Schedule,100% of BCBS PPO fee schedule,156.54,58.75,,55.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,125.23,47,,9.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,125.23,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,13.73,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.73,156.54,
"CORTISOL, URINE",4018659,CDM,307,RC,82530,HCPCS,Outpatient,,,176.10,176.10,,103.46,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,103.46,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,85.25,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.43,100,,20.16,fee Schedule,100% of BCBS fee schedule,20.43,100,,8.64,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,82.77,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,20.43,100,,8.64,Fee Schedule,100% of BCBS PPO fee schedule,103.46,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,82.77,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,82.77,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,13.54,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.54,103.46,
LAMOTRIGINE (LAMICTAL),4018660,CDM,301,RC,80175,HCPCS,Outpatient,,,195.90,195.90,,115.09,58.75,,23.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,115.09,58.75,,23.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,94.84,48.41,,15.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.2,100,,76.68,fee Schedule,100% of BCBS fee schedule,16.2,100,,3.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,92.07,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,16.2,100,,3.96,Fee Schedule,100% of BCBS PPO fee schedule,115.09,58.75,,23.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,92.07,47,,15.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,92.07,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,10.74,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.74,115.09,
PROLACTIN,4018661,CDM,301,RC,84146,HCPCS,Outpatient,,,50.08,50.08,,29.42,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.42,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.24,48.41,,16.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,23.68,100,,29.304,fee Schedule,100% of BCBS fee schedule,23.68,100,,13.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,23.54,47,,16.168,Percent of Total Billed Charges,47% of Total Billed Charges,23.68,100,,13.68,Fee Schedule,100% of BCBS PPO fee schedule,29.42,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.54,47,,16.168,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.54,47,,16.168,Percent of Total Billed Charges,47% of Total Billed Charges,15.7,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15.7,29.42,
"ZINC, PLASMA OR SERUM",4018662,CDM,301,RC,84630,HCPCS,Outpatient,,,88.80,88.80,,52.17,58.75,,62.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,52.17,58.75,,62.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.99,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.92,100,,23.04,fee Schedule,100% of BCBS fee schedule,13.92,100,,18,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,41.74,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,13.92,100,,18,Fee Schedule,100% of BCBS PPO fee schedule,52.17,58.75,,62.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,41.74,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,41.74,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,9.23,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9.23,52.17,
ESTRIOL,4018663,CDM,301,RC,82677,HCPCS,Outpatient,,,144.30,144.30,,84.78,58.75,,98.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.78,58.75,,98.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.86,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,29.56,100,,20.16,fee Schedule,100% of BCBS fee schedule,29.56,100,,13.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,67.82,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,29.56,100,,13.68,Fee Schedule,100% of BCBS PPO fee schedule,84.78,58.75,,98.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,67.82,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,67.82,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,19.58,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19.58,84.78,
CA 125,4018664,CDM,300,RC,86304,HCPCS,Outpatient,,,61.00,61.00,,35.84,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.84,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.53,48.41,,108.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.44,100,,20.16,fee Schedule,100% of BCBS fee schedule,25.44,100,,13.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,28.67,47,,104.904,Percent of Total Billed Charges,47% of Total Billed Charges,25.44,100,,13.68,Fee Schedule,100% of BCBS PPO fee schedule,35.84,58.75,,61.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,104.904,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.67,47,,104.904,Percent of Total Billed Charges,47% of Total Billed Charges,16.86,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.86,35.84,
"IMMUNOGLOBULINS, A,G,M,QUANT",4018665,CDM,302,RC,82784,HCPCS,Outpatient,,,81.00,81.00,,47.59,58.75,,38.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.59,58.75,,38.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.21,48.41,,23.24,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.37,100,,20.16,fee Schedule,100% of BCBS fee schedule,11.37,100,,20.16,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,38.07,47,,22.56,Percent of Total Billed Charges,47% of Total Billed Charges,11.37,100,,20.16,Fee Schedule,100% of BCBS PPO fee schedule,47.59,58.75,,38.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.07,47,,22.56,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,38.07,47,,22.56,Percent of Total Billed Charges,47% of Total Billed Charges,7.53,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.53,47.59,
VARICELLA ZOSTER VIRUS ANTIB.,4018666,CDM,302,RC,86787,HCPCS,Outpatient,,,106.20,106.20,,62.39,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.39,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.41,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.74,100,,20.16,fee Schedule,100% of BCBS fee schedule,15.74,100,,76.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,49.91,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,15.74,100,,76.68,Fee Schedule,100% of BCBS PPO fee schedule,62.39,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.91,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,49.91,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,10.43,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.43,62.39,
"RENIN ACTIVITY, PLASMA",4018667,CDM,301,RC,84244,HCPCS,Outpatient,,,151.45,151.45,,88.98,58.75,,23.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,88.98,58.75,,23.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.32,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,26.88,100,,23.04,fee Schedule,100% of BCBS fee schedule,26.88,100,,29.304,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,71.18,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,26.88,100,,29.304,Fee Schedule,100% of BCBS PPO fee schedule,88.98,58.75,,23.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,71.18,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,71.18,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,17.81,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17.81,88.98,
RIGHT HAND SPLINT,4018668,CDM,521,RC,,,Outpatient,,,10.00,10.00,,5.88,58.75,,10.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.88,58.75,,10.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.84,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,9,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,9,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,5.88,58.75,,10.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.7,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.7,9,
EHRLICHIA CHAFFEENSIS PCR,4018669,CDM,302,RC,86666,HCPCS,Outpatient,,,218.10,218.10,,128.13,58.75,,117.312,Percent of Total Billed Charges,58.75% of Total Billed Charges,128.13,58.75,,117.312,Percent of Total Billed Charges,58.75% of Total Billed Charges,105.58,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.44,100,,156.96,fee Schedule,100% of BCBS fee schedule,12.44,100,,20.16,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,102.51,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,12.44,100,,20.16,Fee Schedule,100% of BCBS PPO fee schedule,128.13,58.75,,117.312,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,102.51,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,102.51,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,8.24,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.24,128.13,
"OXALATE, 24 HR URINE",4018670,CDM,307,RC,83945,HCPCS,Outpatient,,,88.80,88.80,,52.17,58.75,,117.312,Percent of Total Billed Charges,58.75% of Total Billed Charges,52.17,58.75,,117.312,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.99,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.9,100,,85.68,fee Schedule,100% of BCBS fee schedule,15.9,100,,20.16,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,41.74,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,15.9,100,,20.16,Fee Schedule,100% of BCBS PPO fee schedule,52.17,58.75,,117.312,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,41.74,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,41.74,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,11.71,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.71,52.17,
PAP SMEAR,4018671,CDM,300,RC,88175,HCPCS,Outpatient,,,66.00,66.00,,38.78,58.75,,179.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.78,58.75,,179.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.95,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,32.38,100,,21.6,fee Schedule,100% of BCBS fee schedule,32.38,100,,20.16,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,31.02,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,32.38,100,,20.16,Fee Schedule,100% of BCBS PPO fee schedule,38.78,58.75,,179.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.02,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.02,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,21.56,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21.56,38.78,
PROTEIN/CREATININE URINE RANDM,4018672,CDM,301,RC,82570,HCPCS,Outpatient,,,11.84,11.84,,6.96,58.75,,179.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.96,58.75,,179.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.73,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.33,100,,23.04,fee Schedule,100% of BCBS fee schedule,6.33,100,,20.16,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,5.56,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,6.33,100,,20.16,Fee Schedule,100% of BCBS PPO fee schedule,6.96,58.75,,179.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.56,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.56,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.19,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.19,6.96,
AEROBIC BACTERIAL CULTURE,4018673,CDM,306,RC,87070,HCPCS,Outpatient,,,52.74,52.74,,30.98,58.75,,16.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.98,58.75,,16.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.53,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.53,100,,202.32,fee Schedule,100% of BCBS fee schedule,10.53,100,,23.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,24.79,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,10.53,100,,23.04,Fee Schedule,100% of BCBS PPO fee schedule,30.98,58.75,,16.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.79,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,24.79,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.98,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.98,30.98,
EVEROLIMUS,4018674,CDM,301,RC,80169,HCPCS,Outpatient,,,219.33,219.33,,128.86,58.75,,16.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,128.86,58.75,,16.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,106.18,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.79,100,,23.76,fee Schedule,100% of BCBS fee schedule,16.79,100,,7.92,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,103.09,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,16.79,100,,7.92,Fee Schedule,100% of BCBS PPO fee schedule,128.86,58.75,,16.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,103.09,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,103.09,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,11.12,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.12,128.86,
NICOTINE,4018675,CDM,301,RC,80323,HCPCS,Outpatient,,,96.00,96.00,,56.4,58.75,,16.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,56.4,58.75,,16.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.47,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,64.25,100,,78.48,fee Schedule,100% of BCBS fee schedule,64.25,100,,156.96,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,45.12,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,64.25,100,,156.96,Fee Schedule,100% of BCBS PPO fee schedule,56.4,58.75,,16.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.12,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,45.12,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,45.12,64.25,
HSV 1 & 2 ANTIBODIES IGG,4018676,CDM,301,RC,86695,HCPCS,Outpatient,,,112.50,112.50,,66.09,58.75,,16.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.09,58.75,,16.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,54.46,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.12,100,,59.76,fee Schedule,100% of BCBS fee schedule,16.12,100,,85.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,52.88,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,16.12,100,,85.68,Fee Schedule,100% of BCBS PPO fee schedule,66.09,58.75,,16.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,52.88,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,52.88,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,10.68,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.68,66.09,
QUANTIFERON-TB GOLD PLUS,4018677,CDM,301,RC,86480,HCPCS,Outpatient,,,118.55,118.55,,69.65,58.75,,62.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.65,58.75,,62.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.39,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,75.76,100,,3.6,fee Schedule,100% of BCBS fee schedule,75.76,100,,21.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,55.72,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,75.76,100,,21.6,Fee Schedule,100% of BCBS PPO fee schedule,69.65,58.75,,62.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.72,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,55.72,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,50.2,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,50.2,75.76,
COVID-19,4018678,CDM,300,RC,87635,HCPCS,Outpatient,,,130.00,130.00,,76.38,58.75,,127.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.38,58.75,,127.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.93,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,77,100,,15.84,fee Schedule,100% of BCBS fee schedule,77,100,,23.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,61.1,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,77,100,,23.04,Fee Schedule,100% of BCBS PPO fee schedule,76.38,58.75,,127.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,61.1,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,61.1,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,41.56,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,41.56,77,
COVID ANTIBODIES,4018679,CDM,301,RC,86769,HCPCS,Outpatient,,,50.56,50.56,,29.7,58.75,,23.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.7,58.75,,23.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.48,48.41,,2.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.13,100,,26.64,fee Schedule,100% of BCBS fee schedule,42.13,100,,202.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,23.76,47,,2.48,Percent of Total Billed Charges,47% of Total Billed Charges,42.13,100,,202.32,Fee Schedule,100% of BCBS PPO fee schedule,29.7,58.75,,23.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.76,47,,2.48,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.76,47,,2.48,Percent of Total Billed Charges,47% of Total Billed Charges,34.13,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23.76,42.13,
"ID NOW RSV, MOLECULAR",4018680,CDM,300,RC,87634,HCPCS,Outpatient,,,165.00,165.00,,96.94,58.75,,166.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.94,58.75,,166.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.88,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,85.79,100,,38.88,fee Schedule,100% of BCBS fee schedule,85.79,100,,23.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,77.55,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,85.79,100,,23.76,Fee Schedule,100% of BCBS PPO fee schedule,96.94,58.75,,166.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.55,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,77.55,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,56.86,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,56.86,96.94,
"ID NOW STREP A 2, MOLECULAR",4018681,CDM,300,RC,87651,HCPCS,Outpatient,,,132.00,132.00,,77.55,58.75,,164.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,77.55,58.75,,164.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,63.9,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.89,100,,63.36,fee Schedule,100% of BCBS fee schedule,42.89,100,,78.48,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,62.04,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,42.89,100,,78.48,Fee Schedule,100% of BCBS PPO fee schedule,77.55,58.75,,164.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,62.04,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,62.04,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,28.42,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28.42,77.55,
ID NOW INFLUENZA A&B MOLECULAR,4018682,CDM,300,RC,87502,HCPCS,Outpatient,,,210.00,210.00,,123.38,58.75,,129.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,123.38,58.75,,129.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,101.66,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,105.38,100,,126.72,fee Schedule,100% of BCBS fee schedule,105.38,100,,59.76,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,98.7,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,105.38,100,,59.76,Fee Schedule,100% of BCBS PPO fee schedule,123.38,58.75,,129.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,98.7,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,98.7,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,77.6,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,77.6,123.38,
ID NOW COVID 19 MOLECULAR,4018683,CDM,300,RC,87635,HCPCS,Outpatient,,,130.00,130.00,,76.38,58.75,,219.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.38,58.75,,219.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.93,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,77,100,,18,fee Schedule,100% of BCBS fee schedule,77,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,61.1,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,77,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,76.38,58.75,,219.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,61.1,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,61.1,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,41.56,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,41.56,77,
"T3,TOTAL",4018684,CDM,301,RC,84480,HCPCS,Outpatient,,,82.96,82.96,,48.74,58.75,,153.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.74,58.75,,153.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.16,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.33,100,,1390.32,fee Schedule,100% of BCBS fee schedule,17.33,100,,15.84,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,38.99,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,17.33,100,,15.84,Fee Schedule,100% of BCBS PPO fee schedule,48.74,58.75,,153.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.99,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,38.99,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,11.48,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.48,48.74,
COVID-19 ANTIGEN TEST,4018685,CDM,300,RC,87426,HCPCS,Outpatient,,,100.00,100.00,,58.75,58.75,,47.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.75,58.75,,47.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.41,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,45.23,100,,3.6,fee Schedule,100% of BCBS fee schedule,45.23,100,,26.64,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,47,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,45.23,100,,26.64,Fee Schedule,100% of BCBS PPO fee schedule,58.75,58.75,,47.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,28.87,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28.87,58.75,
Urine Albumin/Creat Ratio,4018686,CDM,300,RC,82043,HCPCS,Outpatient,,,49.00,49.00,,28.79,58.75,,76.776,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.79,58.75,,76.776,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.72,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.06,100,,10.8,fee Schedule,100% of BCBS fee schedule,7.06,100,,38.88,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,23.03,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,7.06,100,,38.88,Fee Schedule,100% of BCBS PPO fee schedule,28.79,58.75,,76.776,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.03,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.03,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,4.68,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.68,28.79,
"Buprenorphine, Urine",4018687,CDM,300,RC,80307,HCPCS,Outpatient,,,22.62,22.62,,13.29,58.75,,41.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.29,58.75,,41.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.95,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,71.12,100,,27.36,fee Schedule,100% of BCBS fee schedule,71.12,100,,63.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,10.63,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,71.12,100,,63.36,Fee Schedule,100% of BCBS PPO fee schedule,13.29,58.75,,41.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.63,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.63,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,50.34,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.63,71.12,
Spotfire Resp.Panel Mini,4018688,CDM,306,RC,87631,HCPCS,Outpatient,,,249.60,249.60,,146.64,58.75,,67.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,146.64,58.75,,67.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,120.83,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,156.89,100,,3.6,fee Schedule,100% of BCBS fee schedule,156.89,100,,126.72,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,117.31,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,156.89,100,,126.72,Fee Schedule,100% of BCBS PPO fee schedule,146.64,58.75,,67.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,117.31,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,117.31,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,115.53,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,115.53,156.89,
Spotfire Sore Throat Panel Mini,4018689,CDM,306,RC,87631,HCPCS,Outpatient,,,249.60,249.60,,146.64,58.75,,66.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,146.64,58.75,,66.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,120.83,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,156.89,100,,15.048,fee Schedule,100% of BCBS fee schedule,156.89,100,,18,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,117.31,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,156.89,100,,18,Fee Schedule,100% of BCBS PPO fee schedule,146.64,58.75,,66.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,117.31,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,117.31,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,115.53,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,115.53,156.89,
Spotfire Resp. Panel 15 Target,4018690,CDM,306,RC,87632,HCPCS,Outpatient,,,381.61,381.61,,224.2,58.75,,27.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,224.2,58.75,,27.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,184.74,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,260.85,100,,3.6,fee Schedule,100% of BCBS fee schedule,260.85,100,,1390.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,179.36,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,260.85,100,,1390.32,Fee Schedule,100% of BCBS PPO fee schedule,224.2,58.75,,27.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,179.36,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,179.36,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,176.63,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,176.63,260.85,
Spotfire Sore Throat Panel 14 Target,4018691,CDM,306,RC,87632,HCPCS,Outpatient,,,381.61,381.61,,224.2,58.75,,71.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,224.2,58.75,,71.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,184.74,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,260.85,100,,13.68,fee Schedule,100% of BCBS fee schedule,260.85,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,179.36,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,260.85,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,224.2,58.75,,71.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,179.36,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,179.36,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,176.63,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,176.63,260.85,
"Streptococcus, Group A, APT",4018692,CDM,306,RC,87651,HCPCS,Outpatient,,,35.09,35.09,,20.62,58.75,,76.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.62,58.75,,76.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.99,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.89,100,,43.2,fee Schedule,100% of BCBS fee schedule,42.89,100,,10.8,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,16.49,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,42.89,100,,10.8,Fee Schedule,100% of BCBS PPO fee schedule,20.62,58.75,,76.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.49,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.49,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,28.42,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.49,42.89,
"chlamydia pneumoniae, APT",4018693,CDM,306,RC,87486,HCPCS,Outpatient,,,35.09,35.09,,20.62,58.75,,9.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.62,58.75,,9.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.99,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.89,100,,43.2,fee Schedule,100% of BCBS fee schedule,42.89,100,,27.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,16.49,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,42.89,100,,27.36,Fee Schedule,100% of BCBS PPO fee schedule,20.62,58.75,,9.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.49,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.49,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,28.42,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.49,42.89,
"Mycoplasma pneumoniae, APT",4018694,CDM,306,RC,87581,HCPCS,Outpatient,,,35.09,35.09,,20.62,58.75,,64.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.62,58.75,,64.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.99,48.41,,3.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.89,100,,13.68,fee Schedule,100% of BCBS fee schedule,42.89,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,16.49,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,42.89,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,20.62,58.75,,64.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.49,47,,3.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.49,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,28.42,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.49,42.89,
"Bordetta parapertussis/pertussis, APT",4018695,CDM,306,RC,87798,HCPCS,Outpatient,,,35.09,35.09,,20.62,58.75,,76.776,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.62,58.75,,76.776,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.99,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.89,100,,18.72,fee Schedule,100% of BCBS fee schedule,42.89,100,,15.048,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,16.49,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,42.89,100,,15.048,Fee Schedule,100% of BCBS PPO fee schedule,20.62,58.75,,76.776,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.49,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.49,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,28.42,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.49,42.89,
SURG TISSUE,4040026,CDM,310,RC,88305,HCPCS,Outpatient,,,133.85,133.85,TC,78.64,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,78.64,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.8,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,45.01,100,,15.048,fee Schedule,100% of BCBS fee schedule,45.01,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,62.91,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,45.01,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,78.64,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,62.91,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,62.91,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,41.11,90,,,Fee Schedule,90% of UHC fee schedule,72.43,115,,9.4,Fee Schedule,115% of CMS OPPS Rate,72.43,115,,726.056,Fee Schedule,115% of CMS OPPS Rate,41.11,78.64,
"SURP,PATH,FROX SECT1",4040040,CDM,305,RC,85999,HCPCS,Outpatient,,,272.00,272.00,,159.8,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,159.8,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,131.68,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,244.8,90,,15.84,fee Schedule,90% of BCBS fee schedule,244.8,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,127.84,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,244.8,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,159.8,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,127.84,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,127.84,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,127.84,244.8,
"HCG SLIDE, URINE (PREG)",4048573,CDM,300,RC,81025,HCPCS,Outpatient,,,50.00,50.00,,29.38,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.38,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.21,48.41,,15.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.83,100,,36.72,fee Schedule,100% of BCBS fee schedule,8.83,100,,43.2,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,23.5,47,,15.416,Percent of Total Billed Charges,47% of Total Billed Charges,8.83,100,,43.2,Fee Schedule,100% of BCBS PPO fee schedule,29.38,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.5,47,,15.416,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.5,47,,15.416,Percent of Total Billed Charges,47% of Total Billed Charges,6.98,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.98,29.38,
CULTURE VIRAL,4048584,CDM,306,RC,87252,HCPCS,Outpatient,,,354.09,354.09,,208.03,58.75,,15.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,208.03,58.75,,15.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,171.41,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,31.87,100,,4.32,fee Schedule,100% of BCBS fee schedule,31.87,100,,43.2,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,166.42,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,31.87,100,,43.2,Fee Schedule,100% of BCBS PPO fee schedule,208.03,58.75,,15.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,166.42,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,166.42,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,21.11,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21.11,208.03,
PACKED RBC,4080018,CDM,390,RC,85014,HCPCS,Outpatient,,,349.80,349.80,,205.51,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,205.51,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,169.34,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.89,100,,55.44,fee Schedule,100% of BCBS fee schedule,2.89,100,,13.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,164.41,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,2.89,100,,13.68,Fee Schedule,100% of BCBS PPO fee schedule,205.51,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,164.41,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,164.41,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,351.92,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.89,351.92,
WASHED RBC,4080022,CDM,390,RC,,,Outpatient,,,276.00,276.00,,162.15,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,162.15,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,133.61,48.41,,22.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,248.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,248.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,129.72,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,248.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,162.15,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,129.72,47,,21.432,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,129.72,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,350,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,129.72,350,
BLOOD/UNIT,4080023,CDM,381,RC,P9021,HCPCS,Outpatient,,,466.00,466.00,,273.78,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,273.78,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,225.59,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,127.16,100,,3.6,fee Schedule,100% of BCBS fee schedule,127.16,100,,15.048,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,219.02,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,127.16,100,,15.048,Fee Schedule,100% of BCBS PPO fee schedule,273.78,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,219.02,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,219.02,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,350,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,127.16,350,
BLOOD/WHOLE/PROCES,4080026,CDM,390,RC,P9021,HCPCS,Outpatient,1,UN,325.84,325.84,,191.43,58.75,,20.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,191.43,58.75,,20.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,157.74,48.41,,38.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,127.16,100,,23.04,fee Schedule,100% of BCBS fee schedule,127.16,100,,15.84,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,153.14,47,,37.224,Percent of Total Billed Charges,47% of Total Billed Charges,127.16,100,,15.84,Fee Schedule,100% of BCBS PPO fee schedule,191.43,58.75,,20.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,153.14,47,,37.224,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,153.14,47,,37.224,Percent of Total Billed Charges,47% of Total Billed Charges,350,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,127.16,350,
FRSH FROZ PLASMA,4080033,CDM,390,RC,83051,HCPCS,Outpatient,,,102.00,102.00,,59.93,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,59.93,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.38,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.93,100,,4.32,fee Schedule,100% of BCBS fee schedule,8.93,100,,36.72,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,47.94,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,100,,36.72,Fee Schedule,100% of BCBS PPO fee schedule,59.93,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47.94,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47.94,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,355.92,100,,,Case Rate,Pays based on per visit rate,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.93,355.92,
PSA SCREENING,4080040,CDM,301,RC,G0103,HCPCS,Outpatient,,,163.35,163.35,,95.97,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,95.97,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.08,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.48,100,,108,fee Schedule,100% of BCBS fee schedule,22.48,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,76.77,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,22.48,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,95.97,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,76.77,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,76.77,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,15.64,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15.64,95.97,
HIV,4080041,CDM,302,RC,86703,HCPCS,Outpatient,,,88.00,88.00,,51.7,58.75,,131.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.7,58.75,,131.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.6,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.75,100,,66.96,fee Schedule,100% of BCBS fee schedule,16.75,100,,55.44,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,41.36,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,16.75,100,,55.44,Fee Schedule,100% of BCBS PPO fee schedule,51.7,58.75,,131.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,41.36,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,41.36,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,11.11,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.11,51.7,
ROCKY MT FEVER,4080042,CDM,302,RC,86757,HCPCS,Outpatient,,,144.30,144.30,,84.78,58.75,,28.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.78,58.75,,28.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.86,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,23.66,100,,13.68,fee Schedule,100% of BCBS fee schedule,23.66,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,67.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,23.66,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,84.78,58.75,,28.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,67.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,67.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,15.68,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15.68,84.78,
HELICOBACTER PYLORI,4080044,CDM,300,RC,86677,HCPCS,Outpatient,,,141.10,141.10,,82.9,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,82.9,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,68.31,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.36,100,,27.36,fee Schedule,100% of BCBS fee schedule,18.36,100,,3.6,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,66.32,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,18.36,100,,3.6,Fee Schedule,100% of BCBS PPO fee schedule,82.9,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,66.32,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,66.32,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,13.65,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.65,82.9,
IGE,4080046,CDM,302,RC,82785,HCPCS,Outpatient,,,58.00,58.00,,34.08,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.08,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.08,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.12,100,,69.12,fee Schedule,100% of BCBS fee schedule,20.12,100,,23.04,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,27.26,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,20.12,100,,23.04,Fee Schedule,100% of BCBS PPO fee schedule,34.08,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.26,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,27.26,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,13.33,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.33,34.08,
VANCOMYCIN PEAK,4080047,CDM,301,RC,80202,HCPCS,Outpatient,,,151.25,151.25,,88.86,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,88.86,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.22,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.56,100,,20.16,fee Schedule,100% of BCBS fee schedule,16.56,100,,4.32,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,71.09,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,16.56,100,,4.32,Fee Schedule,100% of BCBS PPO fee schedule,88.86,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,71.09,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,71.09,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,10.97,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.97,88.86,
MYCOPLASMA,4080048,CDM,300,RC,86738,HCPCS,Outpatient,,,163.00,163.00,,95.76,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,95.76,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,78.91,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.18,100,,13.68,fee Schedule,100% of BCBS fee schedule,16.18,100,,108,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,76.61,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,16.18,100,,108,Fee Schedule,100% of BCBS PPO fee schedule,95.76,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,76.61,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,76.61,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,10.73,90,,,Fee Schedule,90% of UHC fee schedule,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.73,95.76,
VENIPUNCTURE,4080049,CDM,300,RC,36415,HCPCS,Outpatient,,,19.95,19.95,,11.72,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.72,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.66,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9.38,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,11.72,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.38,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.38,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.43,90,,,Fee Schedule,90% of UHC fee schedule,9.38,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,9.38,47,,28.952,Percent of Total Billed Charges,47% of Total Billed Charges,2.43,11.72,
RSV TEST,4080053,CDM,302,RC,87280,HCPCS,Outpatient,,,136.40,136.40,,80.14,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,80.14,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.03,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.76,100,,10.08,fee Schedule,100% of BCBS fee schedule,14.76,100,,69.12,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,64.11,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,14.76,100,,69.12,Fee Schedule,100% of BCBS PPO fee schedule,80.14,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,64.11,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,64.11,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,10.87,90,,,Fee Schedule,90% of UHC fee schedule,64.11,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,64.11,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,10.87,80.14,
PSA DIAGNOSTIC,4080054,CDM,301,RC,84153,HCPCS,Outpatient,,,163.35,163.35,,95.97,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,95.97,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.08,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.48,100,,27.904,fee Schedule,100% of BCBS fee schedule,22.48,100,,20.16,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,76.77,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,22.48,100,,20.16,Fee Schedule,100% of BCBS PPO fee schedule,95.97,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,76.77,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,76.77,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,14.9,90,,,Fee Schedule,90% of UHC fee schedule,76.77,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,76.77,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,14.9,95.97,
EMPLOYER DRUG SCREEN,4080055,CDM,300,RC,80305,HCPCS,Outpatient,,,40.00,40.00,,23.5,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.5,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.36,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.8,100,,34.2,fee Schedule,100% of BCBS fee schedule,13.8,100,,13.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,18.8,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,13.8,100,,13.68,Fee Schedule,100% of BCBS PPO fee schedule,23.5,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.8,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,10.21,90,,,Fee Schedule,90% of UHC fee schedule,18.8,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,47,,56.4,Percent of Total Billed Charges,47% of Total Billed Charges,10.21,23.5,
UA TEST STRIP ONLY,4501000,CDM,300,RC,81003,HCPCS,Outpatient,,,28.00,28.00,,16.45,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,16.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.74,100,,63.36,fee Schedule,100% of BCBS fee schedule,2.74,100,,13.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,13.16,47,,16.168,Percent of Total Billed Charges,47% of Total Billed Charges,2.74,100,,13.68,Fee Schedule,100% of BCBS PPO fee schedule,16.45,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,16.168,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,16.168,Percent of Total Billed Charges,47% of Total Billed Charges,1.83,90,,,Fee Schedule,90% of UHC fee schedule,13.16,47,,56.4,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,47,,34.968,Percent of Total Billed Charges,47% of Total Billed Charges,1.83,16.45,
PREG-URINE ONLY,4501001,CDM,300,RC,81025,HCPCS,Outpatient,,,30.00,30.00,,17.63,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.63,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.52,48.41,,3.832,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.83,100,,99.36,fee Schedule,100% of BCBS fee schedule,8.83,100,,18.216,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,14.1,47,,3.72,Percent of Total Billed Charges,47% of Total Billed Charges,8.83,100,,18.216,Fee Schedule,100% of BCBS PPO fee schedule,17.63,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,3.72,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.1,47,,3.72,Percent of Total Billed Charges,47% of Total Billed Charges,6.98,90,,,Fee Schedule,90% of UHC fee schedule,14.1,47,,34.968,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,6.98,17.63,
STOOL,4501002,CDM,300,RC,82272,HCPCS,Outpatient,,,34.00,34.00,,19.98,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.98,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.46,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.34,100,,27.36,fee Schedule,100% of BCBS fee schedule,4.34,100,,49.68,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,15.98,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.34,100,,49.68,Fee Schedule,100% of BCBS PPO fee schedule,19.98,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.98,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.98,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.43,90,,,Fee Schedule,90% of UHC fee schedule,15.98,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,15.98,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,3.43,19.98,
BLOOD SUGAR FINGER,4501003,CDM,300,RC,82962,HCPCS,Outpatient,,,24.00,24.00,,14.1,58.75,,3.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.1,58.75,,3.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.62,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,3.36,100,,36.72,fee Schedule,100% of BCBS fee schedule,3.36,100,,10.08,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,11.28,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,3.36,100,,10.08,Fee Schedule,100% of BCBS PPO fee schedule,14.1,58.75,,3.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.28,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,2.66,90,,,Fee Schedule,90% of UHC fee schedule,11.28,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,2.66,14.1,
HGB FINGER,4501004,CDM,300,RC,85018,HCPCS,Outpatient,,,20.00,20.00,,11.75,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.89,100,,46.08,fee Schedule,100% of BCBS fee schedule,2.89,100,,27.904,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,9.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.89,100,,27.904,Fee Schedule,100% of BCBS PPO fee schedule,11.75,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,1.92,90,,,Fee Schedule,90% of UHC fee schedule,9.4,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,1.92,11.75,
FLU NASAL SWAB,4501005,CDM,300,RC,87804,HCPCS,Outpatient,,,40.00,40.00,,23.5,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.5,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.36,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.96,100,,90,fee Schedule,100% of BCBS fee schedule,16.96,100,,34.2,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,18.8,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,16.96,100,,34.2,Fee Schedule,100% of BCBS PPO fee schedule,23.5,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.8,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,13.41,90,,,Fee Schedule,90% of UHC fee schedule,18.8,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,13.41,23.5,
STREP SCREEN,4501006,CDM,300,RC,87880,HCPCS,Outpatient,,,43.00,43.00,,25.26,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.26,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.82,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.94,100,,3.6,fee Schedule,100% of BCBS fee schedule,16.94,100,,63.36,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,20.21,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,16.94,100,,63.36,Fee Schedule,100% of BCBS PPO fee schedule,25.26,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.21,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,20.21,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,13.39,90,,,Fee Schedule,90% of UHC fee schedule,20.21,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,20.21,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,13.39,25.26,
INT HOSP CARE MOD,4520105,CDM,987,RC,99222,HCPCS,Outpatient,,,247.00,247.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
SUBSQ HOSP CARE MOD,4520106,CDM,987,RC,99232,HCPCS,Outpatient,,,148.00,148.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
HOSP DISCHARGE MGMT,4520107,CDM,987,RC,99238,HCPCS,Outpatient,,,150.00,150.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
SB ADMIT LOW,4520112,CDM,982,RC,99304,HCPCS,Outpatient,,,149.15,149.15,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
INIT HOS CARE LOW,4520117,CDM,987,RC,,,Outpatient,,,154.00,154.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
NEX 20,4520141,CDM,521,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,59.04,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,0.94,1.8,
IV START,4520142,CDM,521,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.59,4.95,
SUBSQ HOSP LOW,4520191,CDM,987,RC,99231,HCPCS,Outpatient,,,92.50,92.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
EXC B9LES 1.1-2 CM SNHF,4520203,CDM,521,RC,11422,HCPCS,Outpatient,,,279.00,279.00,,163.91,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,163.91,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,135.06,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,1500.8,100,,3.6,fee Schedule,100% of ASC Tier Groupings ,1500.8,100,,72,Fee Schedule,100% of ASC Tier Groupings,131.13,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,1500.8,100,,72,Fee Schedule,100% of ASC Tier Groupings,163.91,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,94.49,100,,,Fee Schedule,100% of ASC Tier Groupings,131.13,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,94.49,100,,,Fee Schedule,100% ASC Tier Groupings,131.13,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,138.83,115,,14.288,Percent of Total Billed Charges,115% of Total Billed Charges,138.83,115,,19.176,Case Rate,Pays based on per visit rate,94.49,1500.8,
A-E,453,CDM,113,RC,,,Inpatient,,,,,,2846,100,,3.288,Per Diem,Pays based on per day rate,2846,100,,3.288,Per Diem,Pays based on per day rate,2345.31,100,,1.936,Per Diem,Pays based on per day rate,3514,100,,41.76,Per Diem,Pays based on per day rate,3514,100,,15.84,Per Diem,Pays based on per day rate,2277,100,,1.88,Per Diem,Pays based on per day rate,3514,100,,15.84,Per diem,Pays based on per day rate,2846,100,,3.288,Per diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,1.88,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,1.88,Per Diem,Pays based on per day rate,2198,100,,,Per diem,Pays based on per day rate,2277,100,,19.176,Per Diem,Pays based on per day rate,2277,100,,24.064,Per Diem,Pays based on per day rate,2198,3514,
EKG TECHNICAL,4600002,CDM,730,RC,93005,HCPCS,Outpatient,,,60.00,60.00,,35.25,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.25,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.05,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,52.81,100,,4.32,fee Schedule,100% of BCBS fee schedule,52.81,100,,15.84,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,28.2,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,52.81,100,,15.84,Fee Schedule,100% of BCBS PPO fee schedule,35.25,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.2,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.2,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,90,100,,,Case Rate,Pays based on per visit rate,5.95,115,,24.064,Fee Schedule,115% of CMS OPPS Rate,5.95,115,,47,Fee Schedule,115% of CMS OPPS Rate,5.95,90,
TYLENOL TAB 325MG,5000002,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,59.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,59.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TYLENOL CHEW 80MG,5000003,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TYLENOL ELIX 10ML UD,5000006,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TYLENOL ELIX 120ML,5000007,CDM,259,RC,,,Outpatient,,,32.00,32.00,,18.8,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.8,90,,151.92,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,15.04,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,28.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,28.8,
TYLENOL ELIX 5ML L,5000010,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,19.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,19.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,15.104,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,41.76,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,14.664,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,41.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,19.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,14.664,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,14.664,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
TYLENOL CAP 500MG,5000015,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,118.8,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
ACETAMIN 120MG SUPP,5000017,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,64.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
ACETAMIN SUPP 325MG,5000018,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,34.92,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ACETAMIN 650MG SUPP,5000019,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,22.464,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,302.4,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,21.808,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
TYLENOL W/COD #3,5000024,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,46.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,46.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,151.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,151.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,46.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TYLENOL W/COD #4,5000027,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TYLENOL EL W/COD 30,5000032,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,6.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,118.8,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,118.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,6.016,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
TYLENOL EL W/COD 5ML,5000033,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,46.088,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,397.44,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,64.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,44.744,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,64.08,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,44.744,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,44.744,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
TOPROL-XL 100MG,5000034,CDM,259,RC,,,Outpatient,,,6.60,6.60,,3.88,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.88,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.2,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.94,90,,53.28,Percent of Total Billed Charges,90% of Total Billed Charges,5.94,90,,34.92,Percent of Total Billed Charges,90% of Total Billed Charges,3.1,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,5.94,90,,34.92,Percent of Total Billed Charges,90% of Total Billed Charges,3.88,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.1,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.1,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.1,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.1,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,3.1,5.94,
ALLOPURINOL 100MG O,5000041,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,98.64,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,302.4,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,302.4,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
ALLOPURINOL 300MG O,5000042,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,79.336,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
ASA ASPIRIN TAB5 GR,5000051,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,98.64,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,79.336,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ASPIRIN 81MG ECECOT,5000053,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
ECOTRIN/EC ASA,5000055,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,156.96,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,397.44,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,397.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,33.464,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
CALAN 80(ISOPTIN) TB,5000073,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,53.28,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,53.28,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,33.464,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,18.24,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
AMARYL TAB 2 MG,5000086,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,98.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,98.64,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,18.24,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,157.92,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
AMERICAINE OINT10OZ,5000090,CDM,270,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,157.92,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
DEPAKOTE 125MG,5000094,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,98.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,98.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CETICAINE SPR,5000106,CDM,259,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,11.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,11.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
FIORINAL O TAB,5000134,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,20.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,20.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,20.528,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,156.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,19.928,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,156.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,20.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,19.928,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,19.928,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,207.552,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ESGIC OR FIORICET TB,5000135,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,4.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,4.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,4.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,207.552,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,27.824,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CARISOPRODOL 350MG O,5000138,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,27.824,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,51.512,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
SOMA COMP O,5000139,CDM,259,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,51.512,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,37.224,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
COVERA HS 180 MG,5000161,CDM,259,RC,,,Outpatient,,,9.00,9.00,,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.36,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.1,90,,46.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.1,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.23,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,37.224,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,47,,51.512,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,8.1,
CYCLOBENZAPRIN 10MG,5000166,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,51.512,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
HEMOCYTE TAB,5000221,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,102.96,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,81.968,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
MIDRIN CAP,5000232,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,205.2,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,81.968,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
XYLOCAINE JELLY2%,5000242,CDM,270,RC,,,Outpatient,,,41.00,41.00,,24.09,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.09,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.85,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,36.9,90,,40.896,Percent of Total Billed Charges,90% of Total Billed Charges,36.9,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,19.27,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,36.9,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,24.09,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.27,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,19.27,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.27,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,19.27,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,19.27,36.9,
ZESTRIL 5MG TAB,5000251,CDM,250,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,74.16,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
LIDOCAINE CAR 100 MG,5000252,CDM,250,RC,,,Outpatient,,,32.00,32.00,,18.8,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,23.432,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.8,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,90,,46.8,Percent of Total Billed Charges,90% of Total Billed Charges,15.04,47,,22.752,Percent of Total Billed Charges,47% of Total Billed Charges,28.8,90,,46.8,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,22.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,22.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,28.8,
XYLOCAINE VIS 100ML,5000253,CDM,259,RC,,,Outpatient,,,57.00,57.00,,33.49,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.49,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.59,48.41,,47.248,Percent of Total Billed Charges,48.41% of Total Billed Charges,51.3,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,51.3,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,26.79,47,,45.872,Percent of Total Billed Charges,47% of Total Billed Charges,51.3,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,33.49,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,45.872,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.79,47,,45.872,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,26.79,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,26.79,51.3,
XYLOCAINE VIS 5ML,5000254,CDM,250,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,102.96,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,102.96,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
MONISTAT DERM 15GM T,5000260,CDM,259,RC,,,Outpatient,,,99.00,99.00,,58.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.93,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,89.1,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,89.1,90,,205.2,Percent of Total Billed Charges,90% of Total Billed Charges,46.53,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,89.1,90,,205.2,Percent of Total Billed Charges,90% of Total Billed Charges,58.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.53,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,46.53,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.53,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,46.53,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,46.53,89.1,
DEMEROL EL 50MG/5ML,5000266,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,40.896,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,40.896,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MEPERGAN FORTISCAP,5000270,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,74.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,74.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ROBAXIN 500MG TAB,5000277,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,37.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,24.44,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ROBAXIN 750MG TAB,5000278,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,24.44,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ICY HOT BALM 105GM,5000286,CDM,270,RC,,,Outpatient,,,28.00,28.00,,16.45,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.2,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,25.2,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,47,,53.768,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,25.2,
BENGAY OINT 1.25OZ,5000287,CDM,270,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,53.768,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,107.16,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
MORPHINE 15MG,5000291,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,107.16,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,21.36,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
QUINAMM O,5000293,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,3.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,21.36,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,38.728,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TYLOX CAP O,5000303,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,18.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,18.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,274.32,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,37.44,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,37.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,18.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,38.728,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
PYRIDIUM 100MG O,5000312,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
PYRIDIUM 200MG O,5000313,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
PROZAC 10MG,5000315,CDM,259,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,59.4,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
QUININE 200MG O,5000336,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,27.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,27.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,27.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
QUININE 300MG O,5000337,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PONTOCAIN/PROPARA OS,5000347,CDM,250,RC,,,Outpatient,,,43.00,43.00,,25.26,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.26,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.82,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,38.7,90,,21.784,Percent of Total Billed Charges,90% of Total Billed Charges,38.7,90,,274.32,Percent of Total Billed Charges,90% of Total Billed Charges,20.21,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,38.7,90,,274.32,Percent of Total Billed Charges,90% of Total Billed Charges,25.26,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.21,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,20.21,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.21,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,20.21,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,20.21,38.7,
ZOVIREX CAP 200MG,5000364,CDM,259,RC,,,Outpatient,,,9.90,9.90,,5.82,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.82,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.79,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.91,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,8.91,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.65,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.91,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,5.82,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.65,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.65,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.65,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,4.65,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,4.65,8.91,
CEPHALEXIN 250MG O,5000365,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,55.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,55.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,19.008,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,55.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
ZYPREZIA 2.5MG,5000371,CDM,259,RC,,,Outpatient,,,28.00,28.00,,16.45,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.2,90,,46.264,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,90,,59.4,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,25.2,90,,59.4,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,25.2,
HEMORRHOIDAL HCSUPP,5000437,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
XANAX 0.25MG TAB,5001002,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
XANAX 0.5MG TAB,5001003,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,21.784,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,21.784,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,143.256,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
XANAX 1MG TAB,5001004,CDM,259,RC,,,Outpatient,,,9.00,9.00,,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.36,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.1,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.23,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,143.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,8.1,
AMITRIPTYLINE 100MG,5001005,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,19.008,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,19.008,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
AMINTRIPTYLINE 10MG,5001006,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,46.264,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,46.264,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,31.024,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
AMITRIPTYLIE 150 MG,5001007,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,31.024,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
AMITRIPTYLINE 25MG,5001008,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,28.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,27.824,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,27.824,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,27.824,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
AMITRIPTYLINE 50MG,5001009,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,56.928,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,55.272,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,55.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,55.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,11.376,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
AMITRIPTYLINE 75MG,5001010,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,11.376,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
BENZTROPINE 1 MG TAB,5001022,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,24.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,24.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,24.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,9.928,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
COGENTIN 1MG TAB O,5001023,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,61.576,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,59.784,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,9.928,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,24.16,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
BENZTROPINE 2MGO,5001024,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,24.16,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
BUSPAR 5MG PO,5001030,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
BUSPAR 10MG PO,5001032,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,19.8,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
SINEMET 10/100 O,5001039,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,48.24,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SINEMET 25/100 O,5001040,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SINEMET 25/250 O,5001041,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CARDIZEM 25MG INJ,5001042,CDM,250,RC,,,Outpatient,,,39.00,39.00,,22.91,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.91,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.88,48.41,,97.984,Percent of Total Billed Charges,48.41% of Total Billed Charges,35.1,90,,11.088,Percent of Total Billed Charges,90% of Total Billed Charges,35.1,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,18.33,47,,95.128,Percent of Total Billed Charges,47% of Total Billed Charges,35.1,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,22.91,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.33,47,,95.128,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.33,47,,95.128,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.33,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,18.33,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,18.33,35.1,
LIBRIUM 10MG,5001056,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
LIBRIUM 25MG,5001058,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,28.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,28.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,48.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,19.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,19.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,28.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,47,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
LIBRIUM 5MG,5001060,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,57.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,57.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,34.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,48.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,33.768,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,48.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,57.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,33.768,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,33.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
THORAZINE 75MG-100 I,5001080,CDM,250,RC,,,Outpatient,,,58.00,58.00,,34.08,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.08,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.08,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,52.2,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,52.2,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,27.26,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,52.2,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,34.08,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.26,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,27.26,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.26,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,27.26,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,27.26,52.2,
KLONOPIN 0.5MG TAB,5001092,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,118.12,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,114.68,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,114.68,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,114.68,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
KLONOPIN 1MG TAB O,5001093,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,152.64,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,11.088,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,11.088,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
VALIUM 10MG,5001116,CDM,259,RC,,,Outpatient,,,16.00,16.00,,9.4,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.4,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.75,48.41,,3.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.4,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,14.4,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,7.52,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,14.4,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.52,47,,3.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.52,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.52,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,7.52,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,7.52,14.4,
VANCOMYCIN 250 CAP,5001117,CDM,259,RC,,,Outpatient,,,119.00,119.00,,69.91,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.91,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.61,48.41,,3.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.1,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,107.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,55.93,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,107.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,69.91,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.93,47,,3.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,55.93,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.93,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,55.93,47,,10.344,Percent of Total Billed Charges,47% of Total Billed Charges,55.93,107.1,
VALIUM 2MG,5001119,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,213.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,214.56,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,207.552,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,207.552,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,207.552,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,10.344,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,25.192,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
VALIUM 5MG,5001121,CDM,259,RC,,,Outpatient,,,12.00,12.00,,7.05,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,25.192,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,52.64,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
DOXYCYCLINE 100MG CA,5001149,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,52.64,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
HALDOL 0.5 MG 0,5001153,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,152.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,152.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,5.792,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
HALDOL 1 MG O,5001155,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,57.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.792,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
HALDOL 2 MG O,5001157,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,22.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,21.432,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
HALDOL 5MG TAB O,5001158,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,53.832,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,214.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,52.264,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,214.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,52.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,52.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
VISTARIL 25MG OGEN,5001163,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
HYDROXYZINE HCL10MG,5001167,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
HYDROXYZINE HCLSYR,5001171,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,79.712,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DOPAMINE 200MG INJ,5001183,CDM,250,RC,,,Outpatient,,,30.00,30.00,,17.63,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.63,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.52,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,27,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,27,90,,57.6,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,27,90,,57.6,Percent of Total Billed Charges,90% of Total Billed Charges,17.63,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.1,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,79.712,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,27,
DOPAMINE 400MG INJ,5001185,CDM,250,RC,,,Outpatient,,,53.00,53.00,,31.14,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.14,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.66,48.41,,44.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,47.7,90,,35.64,Percent of Total Billed Charges,90% of Total Billed Charges,47.7,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,24.91,47,,42.864,Percent of Total Billed Charges,47% of Total Billed Charges,47.7,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,31.14,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.91,47,,42.864,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,24.91,47,,42.864,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.91,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,24.91,47,,32.336,Percent of Total Billed Charges,47% of Total Billed Charges,24.91,47.7,
ESKALITH 300MG CAP,5001187,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,32.336,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,112.048,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ATIVAN 1MG TAB O,5001195,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,112.048,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
ATIVAN 2MG TAB O,5001196,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
LOTENSIN 10MG,5001197,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MECLIZINE 12.5MG,5001206,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,30.08,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MECLIZINE 25MG,5001208,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,35.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,35.64,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,30.08,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
SERAX 10MG CAP O,5001252,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SERAX 15MG O,5001253,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,331.92,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SERAX 30MG O,5001254,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
VASOTEC INJ 1.25MG,5001263,CDM,250,RC,,,Outpatient,,,60.50,60.50,,35.54,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.54,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.29,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,54.45,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,54.45,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,28.44,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,54.45,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,35.54,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.44,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.44,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.44,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,28.44,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,28.44,54.45,
VANTIN 50MG/5MLSUSP,5001264,CDM,259,RC,,,Outpatient,,,122.00,122.00,,71.68,58.75,,34.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,71.68,58.75,,34.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,59.06,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,109.8,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,109.8,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,57.34,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,109.8,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,71.68,58.75,,34.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,57.34,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,57.34,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,57.34,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,57.34,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,57.34,109.8,
PHENOBARB 100MG,5001303,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,69.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,69.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,69.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,18.616,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PHENOBARB 15MG,5001304,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,18.616,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SECTRAL 400MG,5001305,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,9.504,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,331.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,331.92,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
PHENOBARB 20MG/5ML,5001307,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PHENOBARB 30MG O,5001309,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,1348.56,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PHENOBARB 65 MGINJ,5001311,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,1334.88,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
DILANTIN 100 MGO,5001322,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,133.2,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
DILANTIN 125MG/5ML,5001326,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.48,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.48,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.48,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DILANTIN 30MG/5ML,5001329,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,9.504,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,9.504,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,173.336,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CELEBREX 100MG CAP,5001335,CDM,259,RC,,,Outpatient,,,9.00,9.00,,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.36,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.1,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.1,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.23,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,173.336,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,8.1,
VITAMIN C,5001353,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,118.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,118.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,1348.56,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,1348.56,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,118.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
RESTORIL 15MG CAP,5001365,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,1334.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,1334.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
RESTORIL 30MG CAP,5001366,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,58.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,58.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,133.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,133.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,58.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,21.056,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MELLARIL 100MG,5001367,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,42.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,42.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,42.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,21.056,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MELLARIL 10MG,5001372,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,3.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,4.96,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MELLARIL 15 MG,5001374,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,143.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,143.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,143.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.96,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MELLARIL 25MG,5001376,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,704.248,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MELLARIL 50MG,5001382,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,308.16,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,704.248,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,697.104,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
NAVANE 10MG,5001383,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,697.104,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,69.56,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
NAVANE 2MG,5001386,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,259.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,259.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,10.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,259.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,10.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,69.56,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
NAVANE 5MG,5001387,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,17.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,16.92,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TRAZADONE 100MG,5001392,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,17.424,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TRAZADONE 50MG,5001393,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,26.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,185.76,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,25.944,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
TRIHEXAPHENIOYL2MGO,5001409,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,39.504,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,308.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,38.352,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,308.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,38.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,38.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TRIHEXAPHENIOYL5MG,5001413,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,62.352,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,60.536,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,60.536,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,60.536,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PLENDIL 5MG,5001427,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,65.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,65.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,65.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CLONIDINE 0.2MG,5002002,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,30.24,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
ACETYLCYSTEINE 10% 1,5002010,CDM,250,RC,,,Outpatient,,,74.00,74.00,,43.48,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,43.48,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.82,48.41,,11.504,Percent of Total Billed Charges,48.41% of Total Billed Charges,66.6,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,66.6,90,,17.424,Percent of Total Billed Charges,90% of Total Billed Charges,34.78,47,,11.168,Percent of Total Billed Charges,47% of Total Billed Charges,66.6,90,,17.424,Percent of Total Billed Charges,90% of Total Billed Charges,43.48,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,34.78,47,,11.168,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,34.78,47,,11.168,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,34.78,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,34.78,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,34.78,66.6,
ACETYLYSTEINE 20% 30,5002016,CDM,250,RC,,,Outpatient,,,147.00,147.00,,86.36,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.36,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,71.16,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,132.3,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,132.3,90,,185.76,Percent of Total Billed Charges,90% of Total Billed Charges,69.09,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,132.3,90,,185.76,Percent of Total Billed Charges,90% of Total Billed Charges,86.36,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,69.09,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,69.09,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,69.09,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,69.09,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,69.09,132.3,
PROVENTIL 2MG TAB,5002022,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,8.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,160.928,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PROVENTIL 4MG TAB,5002023,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,53.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,53.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,53.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,160.928,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,28.952,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ALBUTEROL HFA INHAL,5002024,CDM,259,RC,,,Outpatient,,,159.00,159.00,,93.41,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,93.41,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.97,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,143.1,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,143.1,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,74.73,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,143.1,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,93.41,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,74.73,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,74.73,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,74.73,47,,28.952,Percent of Total Billed Charges,47% of Total Billed Charges,74.73,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,74.73,143.1,
AMBIEN 5MG,5002028,CDM,259,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,299.52,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,30.24,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,30.24,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
MODURETIC5/50 TAB,5002031,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,37.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,36.848,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,9.096,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TENORMIN 100MG TAB,5002056,CDM,259,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,9.096,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,97.008,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
BUMEX 1MG TAB,5002081,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,97.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
CAPTOPRIL 25MG TAB,5002085,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CAPTOPRIL 12.5MG TAB,5002086,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ROCEPHIN 1 GM,5002091,CDM,250,RC,,,Outpatient,,,253.00,253.00,,148.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,148.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,122.48,48.41,,6.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,227.7,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,227.7,90,,299.52,Percent of Total Billed Charges,90% of Total Billed Charges,118.91,47,,6.208,Percent of Total Billed Charges,47% of Total Billed Charges,227.7,90,,299.52,Percent of Total Billed Charges,90% of Total Billed Charges,148.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,118.91,47,,6.208,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,118.91,47,,6.208,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,118.91,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,118.91,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,118.91,227.7,
RONDEC DROPS 30ML,5002094,CDM,259,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
ROCEPHIN 500MG INJ,5002095,CDM,250,RC,,,Outpatient,,,125.00,125.00,,73.44,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.44,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,60.51,48.41,,33.696,Percent of Total Billed Charges,48.41% of Total Billed Charges,112.5,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,112.5,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,58.75,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,112.5,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,73.44,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,58.75,47,,32.712,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,58.75,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,58.75,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,58.75,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,58.75,112.5,
ROCEPHIN 250MG INJ,5002099,CDM,250,RC,,,Outpatient,,,89.80,89.80,,52.76,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,52.76,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,43.47,48.41,,14.056,Percent of Total Billed Charges,48.41% of Total Billed Charges,80.82,90,,134.176,Percent of Total Billed Charges,90% of Total Billed Charges,80.82,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,42.21,47,,13.648,Percent of Total Billed Charges,47% of Total Billed Charges,80.82,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,52.76,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,42.21,47,,13.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,42.21,47,,13.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,42.21,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,42.21,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,42.21,80.82,
TENORMIN,5002116,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,21.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,21.096,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,21.096,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,21.096,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
COMBIVENT INHALER,5002123,CDM,259,RC,,,Outpatient,,,305.00,305.00,,179.19,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,179.19,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,147.65,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,274.5,90,,254.344,Percent of Total Billed Charges,90% of Total Billed Charges,274.5,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,143.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,274.5,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,179.19,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,143.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,143.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,143.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,143.35,47,,18.048,Percent of Total Billed Charges,47% of Total Billed Charges,143.35,274.5,
QUINIDEX EXT O,5002157,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,91.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,18.048,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,156.416,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
NORVASC 5MG TAB,5002170,CDM,259,RC,,,Outpatient,,,10.00,10.00,,5.88,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.88,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.84,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,9,90,,115.2,Percent of Total Billed Charges,90% of Total Billed Charges,9,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,9,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,5.88,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.7,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,156.416,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,9,
HYZAAR 50/12.5MG TB,5002177,CDM,259,RC,,,Outpatient,,,9.00,9.00,,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.36,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.1,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.1,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.23,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,8.1,
BAYTET 250 UNITINJ,5002178,CDM,250,RC,,,Outpatient,,,552.00,552.00,,324.3,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,324.3,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,267.22,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,496.8,90,,114.48,Percent of Total Billed Charges,90% of Total Billed Charges,496.8,90,,134.176,Percent of Total Billed Charges,90% of Total Billed Charges,259.44,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,496.8,90,,134.176,Percent of Total Billed Charges,90% of Total Billed Charges,324.3,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,259.44,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,259.44,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,259.44,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,259.44,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,259.44,496.8,
REMERON 30MG CAP,5002180,CDM,259,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,83.52,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,18.048,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
ATROVENT 2.5 CCVIAL,5002182,CDM,250,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,3.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,3.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,254.344,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,254.344,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,3.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,18.048,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
CATAPRES 0.1MG O,5002183,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,11.88,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,91.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,91.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CATAPRES 0.2MG O,5002184,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,115.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,115.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DIFLUCAN 150MG,5002222,CDM,259,RC,,,Outpatient,,,57.00,57.00,,33.49,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.49,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.59,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,51.3,90,,352.8,Percent of Total Billed Charges,90% of Total Billed Charges,51.3,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,26.79,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,51.3,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,33.49,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.79,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,26.79,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,26.79,51.3,
LANOXIN PED 60ML,5002225,CDM,259,RC,,,Outpatient,,,139.00,139.00,,81.66,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,81.66,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,67.29,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,125.1,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,125.1,90,,114.48,Percent of Total Billed Charges,90% of Total Billed Charges,65.33,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,125.1,90,,114.48,Percent of Total Billed Charges,90% of Total Billed Charges,81.66,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,65.33,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,65.33,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,65.33,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,65.33,47,,70.064,Percent of Total Billed Charges,47% of Total Billed Charges,65.33,125.1,
CARDIZEM 30MG TAB,5002228,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,76.824,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,83.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,83.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,70.064,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CARDIZEM 60MG TAB,5002229,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,132.824,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DIPYRIDAMOLE 25MG,5002240,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,1617.84,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,11.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,11.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,132.824,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,47.752,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DIPYRIDAMOLE 75MG,5002242,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,170.64,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,47.752,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,60.16,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ELOCON CR,5002266,CDM,270,RC,,,Outpatient,,,114.00,114.00,,66.98,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.98,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,55.19,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,102.6,90,,92.88,Percent of Total Billed Charges,90% of Total Billed Charges,102.6,90,,352.8,Percent of Total Billed Charges,90% of Total Billed Charges,53.58,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,102.6,90,,352.8,Percent of Total Billed Charges,90% of Total Billed Charges,66.98,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,53.58,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,53.58,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,53.58,47,,60.16,Percent of Total Billed Charges,47% of Total Billed Charges,53.58,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,53.58,102.6,
LASIX 20MG TAB,5002302,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
LASIX 40MG,5002303,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,76.824,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,76.824,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,43.616,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
LASIX 80MG TAB,5002304,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,22.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,21.432,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,43.616,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
GUIATUSS DM SYRP 5ML,5002330,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,21.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,21.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,1617.84,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,1617.84,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,21.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,6.208,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
GUIATUSS AC 5 ML,5002334,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,113.088,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,170.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,109.792,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,170.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,109.792,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,109.792,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.208,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
IOPHEN DM ELIX 5ML,5002335,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,30.24,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,92.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,92.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,184.24,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
HYDROCHLORTHIAZIDE,5002351,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,47.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,47.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,47.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,184.24,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
HYDROCHLORTHAZIDE 50,5002352,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,75.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,75.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,75.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,40.12,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DYAZIDE,5002356,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,40.12,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
ISMO 20MG,5002380,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,844.872,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
IMDUR TAB 60MG,5002382,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,13.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,13.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,13.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,844.872,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,89.112,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
ISUPREL IT-USE,5002399,CDM,259,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,30.24,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,30.24,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,89.112,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,48.504,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
ISORDIL 10MG SUBL,5002415,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,48.504,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ISORDIL 10MG O,5002416,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ISORDIL 20MG TAB O,5002419,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ISORDIL 30MG ORAL,5002420,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ISORDIL 40MG 0,5002421,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ISORDIL 5MG O,5002426,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
VASOTEC 5MG,5002429,CDM,259,RC,,,Outpatient,,,6.60,6.60,,3.88,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.88,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.2,48.41,,136.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.94,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,5.94,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,3.1,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,5.94,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,3.88,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.1,47,,132.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.1,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.1,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,3.1,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,3.1,5.94,
VERAPAMIL 40MG TAB,5002430,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ISOSORBIDE 40MGO,5002431,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,12.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,12.408,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ENLON INJ 1CC,5002451,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,7.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,7.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,85.976,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,10.296,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,83.472,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,7.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,83.472,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,83.472,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
ADVIL SUSP 4 OZ,5002457,CDM,259,RC,,,Outpatient,,,32.00,32.00,,18.8,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.8,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,15.04,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,28.8,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,28.8,
ZAROXOLYN 10MG,5002464,CDM,259,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,40.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,40.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,40.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
ZAROXOLYN 2.5MG,5002465,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,17.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,17.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,11.232,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,17.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,10.904,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
ZAROXOLYN 5MG,5002466,CDM,259,RC,,,Outpatient,,,9.00,9.00,,5.29,58.75,,26.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.29,58.75,,26.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.36,48.41,,12.352,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.1,90,,241.92,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,47,,11.992,Percent of Total Billed Charges,47% of Total Billed Charges,8.1,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,58.75,,26.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,11.992,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.23,47,,11.992,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,8.1,
LOPRESSOR TAB 100MG,5002467,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,85.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,83.288,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,83.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,83.288,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
METOPROLOL 50 MG TAB,5002468,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,25.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,89.28,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,10.296,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,10.296,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,24.816,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
PROCARDIA 10MG CAP,5002482,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,243.36,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
NITROGLYCERIN 2.5 PO,5002492,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
NITROSTAT TAB STR 25,5002495,CDM,250,RC,,,Outpatient,,,27.00,27.00,,15.86,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.86,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.07,48.41,,40.28,Percent of Total Billed Charges,48.41% of Total Billed Charges,24.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,24.3,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,12.69,47,,39.104,Percent of Total Billed Charges,47% of Total Billed Charges,24.3,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,15.86,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,39.104,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.69,47,,39.104,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,24.3,
NORTOBID OINT 1OZ,5002506,CDM,270,RC,,,Outpatient,,,45.00,45.00,,26.44,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,26.44,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.78,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,40.5,90,,395.28,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,90,,241.92,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,40.5,90,,241.92,Percent of Total Billed Charges,90% of Total Billed Charges,26.44,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.15,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,21.15,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.15,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,21.15,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,21.15,40.5,
NITROBID OINT DOSE,5002508,CDM,270,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,8.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,74.448,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,7.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
TRANSDERM SCOP PATCH,5002510,CDM,250,RC,,,Outpatient,,,69.00,69.00,,40.54,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.54,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.4,48.41,,40.28,Percent of Total Billed Charges,48.41% of Total Billed Charges,62.1,90,,110.16,Percent of Total Billed Charges,90% of Total Billed Charges,62.1,90,,89.28,Percent of Total Billed Charges,90% of Total Billed Charges,32.43,47,,39.104,Percent of Total Billed Charges,47% of Total Billed Charges,62.1,90,,89.28,Percent of Total Billed Charges,90% of Total Billed Charges,40.54,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.43,47,,39.104,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,32.43,47,,39.104,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.43,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,32.43,47,,5.376,Percent of Total Billed Charges,47% of Total Billed Charges,32.43,62.1,
CIPRO 200MG INJ,5002527,CDM,250,RC,,,Outpatient,,,102.00,102.00,,59.93,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,59.93,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.38,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,91.8,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,91.8,90,,243.36,Percent of Total Billed Charges,90% of Total Billed Charges,47.94,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,91.8,90,,243.36,Percent of Total Billed Charges,90% of Total Billed Charges,59.93,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47.94,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47.94,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47.94,47,,5.376,Percent of Total Billed Charges,47% of Total Billed Charges,47.94,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,47.94,91.8,
CIPRO 400MG INJ,5002528,CDM,250,RC,,,Outpatient,,,161.00,161.00,,94.59,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,94.59,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,77.94,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,144.9,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,144.9,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,75.67,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,144.9,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,94.59,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,75.67,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,75.67,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,75.67,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,75.67,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,75.67,144.9,
CLIDINIUM/CDZP CAP,5002530,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,299.52,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
BUMETANIDE 2MG TAB,5002531,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,395.28,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,395.28,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,126.336,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
AFRIN SPRAY 15ML 1,5002537,CDM,259,RC,,,Outpatient,,,29.70,29.70,,17.45,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.45,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.38,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,26.73,90,,337.68,Percent of Total Billed Charges,90% of Total Billed Charges,26.73,90,,74.448,Percent of Total Billed Charges,90% of Total Billed Charges,13.96,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,26.73,90,,74.448,Percent of Total Billed Charges,90% of Total Billed Charges,17.45,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.96,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.96,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.96,47,,126.336,Percent of Total Billed Charges,47% of Total Billed Charges,13.96,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,13.96,26.73,
PEDIAPRED LIQUID 5ML,5002544,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,9.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,102.24,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,110.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,110.16,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,9.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,46.624,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
PEPCID IV 20MG/2ML,5002563,CDM,250,RC,,,Outpatient,,,20.90,20.90,,12.28,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.28,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.12,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.81,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,18.81,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,9.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,18.81,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,12.28,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,46.624,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,47,,127.088,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,18.81,
REGLAN 5 MG TAB,5002571,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,127.088,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
ROBITUSSIN 4 0ZBOTT,5002574,CDM,259,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,13.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,299.52,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,299.52,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,13.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
ROBITUSSIN 5 MLL,5002576,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,196.416,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,206.424,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
CHARCOAL 25GM,5002578,CDM,259,RC,,,Outpatient,,,98.00,98.00,,57.58,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.58,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.44,48.41,,49.96,Percent of Total Billed Charges,48.41% of Total Billed Charges,88.2,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,88.2,90,,337.68,Percent of Total Billed Charges,90% of Total Billed Charges,46.06,47,,48.504,Percent of Total Billed Charges,47% of Total Billed Charges,88.2,90,,337.68,Percent of Total Billed Charges,90% of Total Billed Charges,57.58,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.06,47,,48.504,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,46.06,47,,48.504,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.06,47,,206.424,Percent of Total Billed Charges,47% of Total Billed Charges,46.06,47,,38.88,Percent of Total Billed Charges,47% of Total Billed Charges,46.06,88.2,
NIZORAL TAB,5002580,CDM,259,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,31.368,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,102.24,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,30.456,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,102.24,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,30.456,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,30.456,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,38.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,57.528,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
ROBITUSSIN AC DOSE,5002583,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,137.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,137.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,137.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,57.528,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,103.4,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ROBITUSSIN DM 5ML L,5002584,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,103.4,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,103.4,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
ROBITUSSIN-DM 10ML,5002586,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,3.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,136.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,103.4,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,156.416,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SINGULAR 10MG TAB,5002590,CDM,259,RC,,,Outpatient,,,16.50,16.50,,9.69,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.69,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.99,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.85,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,14.85,90,,196.416,Percent of Total Billed Charges,90% of Total Billed Charges,7.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,14.85,90,,196.416,Percent of Total Billed Charges,90% of Total Billed Charges,9.69,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.76,47,,156.416,Percent of Total Billed Charges,47% of Total Billed Charges,7.76,47,,141,Percent of Total Billed Charges,47% of Total Billed Charges,7.76,14.85,
ROBITUSSN-DM 4 OZ BO,5002598,CDM,259,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,141,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,176.344,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
KAYEXALATE 15 GM O,5002619,CDM,259,RC,,,Outpatient,,,87.00,87.00,,51.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.12,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,78.3,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,78.3,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,40.89,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,78.3,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,51.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.89,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.89,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.89,47,,176.344,Percent of Total Billed Charges,47% of Total Billed Charges,40.89,47,,53.392,Percent of Total Billed Charges,47% of Total Billed Charges,40.89,78.3,
KAYEXALATE 20GM,5002621,CDM,259,RC,,,Outpatient,,,36.30,36.30,,21.33,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.33,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.57,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,32.67,90,,141.84,Percent of Total Billed Charges,90% of Total Billed Charges,32.67,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,17.06,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,32.67,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,21.33,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.06,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.06,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.06,47,,53.392,Percent of Total Billed Charges,47% of Total Billed Charges,17.06,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,17.06,32.67,
KAYEXALATE 30GMPO,5002622,CDM,259,RC,,,Outpatient,,,56.10,56.10,,32.96,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.96,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.16,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,50.49,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,50.49,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,26.37,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,50.49,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,32.96,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.37,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.37,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.37,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,26.37,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,26.37,50.49,
SSKI SOL 30ML L,5002635,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,136.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,136.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PROCAINAMIDE 250 MG,5002643,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,31.76,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,30.832,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,102.576,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PREM-PRO 0.625/25MG,5002648,CDM,259,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,31.76,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,30.832,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,102.576,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
PROCAN SR 500MGTAB,5002650,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,9.296,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,182.88,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,9.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PROCAN SR 750MGPO,5002651,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,141.84,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,141.84,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PHENERGAN EXP 5ML L,5002656,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,31.76,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,11.344,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,30.832,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PHENERGAN EXP 30ML,5002660,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,28.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,99.36,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,27.824,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,27.824,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,27.824,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,71.44,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PHENER EXP W/COD,5002662,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,53.856,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,71.44,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PHENERGAN VC 5ML,5002674,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PROPRANOLOL 10MG TAB,5002682,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,104.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,104.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,107.28,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,182.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,182.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,104.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PROPRANOLOL 20MG TAB,5002683,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,74.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PROPRANOLOL 40MG TAB,5002684,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,11.344,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,11.344,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,74.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
INDERAL 80MG TAB O,5002687,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,6.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,68.4,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,99.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,99.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.768,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
INDERIDE 40-25 TAB,5002689,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,14.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,14.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,80.176,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,53.856,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,53.856,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,14.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,205.296,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
INDERIDE 80-25 TAB,5002690,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,104.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,104.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,33.768,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,33.264,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,32.784,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,104.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,32.784,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,32.784,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,205.296,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,131.6,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SUDAFED 30MG O,5002694,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,216.216,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,107.28,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,107.28,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,131.6,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TUSSIONEX 5ML,5002702,CDM,259,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,14.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,13.912,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
CLONIDINE 0.1MG,5002716,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,5.92,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
CO-LYTE GAL,5002717,CDM,250,RC,,,Outpatient,,,57.00,57.00,,33.49,58.75,,48.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.49,58.75,,48.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.59,48.41,,11.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,51.3,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,51.3,90,,68.4,Percent of Total Billed Charges,90% of Total Billed Charges,26.79,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,51.3,90,,68.4,Percent of Total Billed Charges,90% of Total Billed Charges,33.49,58.75,,48.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,11.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.79,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,5.92,Percent of Total Billed Charges,47% of Total Billed Charges,26.79,47,,51.888,Percent of Total Billed Charges,47% of Total Billed Charges,26.79,51.3,
QUINIDINE 200MGO,5002721,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,23.432,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,80.176,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,22.752,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,80.176,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,22.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,22.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,51.888,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,28.128,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SEREVENT INHALER,5002732,CDM,259,RC,,,Outpatient,,,292.00,292.00,,171.55,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,171.55,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,141.36,48.41,,10.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,262.8,90,,9.904,Percent of Total Billed Charges,90% of Total Billed Charges,262.8,90,,33.264,Percent of Total Billed Charges,90% of Total Billed Charges,137.24,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,262.8,90,,33.264,Percent of Total Billed Charges,90% of Total Billed Charges,171.55,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,137.24,47,,10.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,137.24,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,137.24,47,,28.128,Percent of Total Billed Charges,47% of Total Billed Charges,137.24,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,137.24,262.8,
SEROQUEL 25MG TAB,5002734,CDM,259,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,48.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,48.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,3501.36,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,216.216,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,216.216,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,48.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,56.024,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
SOD CHL .9% 3MLL,5002744,CDM,250,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,2772,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,56.024,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
SOD CHLORIDE 5ML RT,5002745,CDM,250,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,22.848,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,209.52,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,22.184,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,22.184,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,22.184,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
SPIRONOLACTONE,5002747,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,179.28,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,35.72,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
ELDERTONIC DOSE,5002762,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,267.84,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,35.72,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,41.864,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
THEO DUR 450MG,5002765,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,10.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,9.904,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,9.904,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,10.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,41.864,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,17.368,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
THEODUR 200MG TAB O,5002769,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,56.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,27,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3501.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,54.52,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3501.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,54.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,54.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,17.368,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,112.912,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
THEOLAIR 250MG TAB,5002771,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,11.232,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,1941.84,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,2772,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,2772,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,10.904,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,112.912,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
THEODUR 300MG TAB O,5002773,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,6.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,209.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,209.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.768,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SLOW K,5002775,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,16.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,16.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,179.28,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,179.28,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,16.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TESSALON 100MG O,5002864,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,267.84,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,267.84,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
ISOPTIN 120MG TAB,5002866,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,60.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,60.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,128.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,256.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,125.208,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,60.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,125.208,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,125.208,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,5.168,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ISOPTIN 80MG TAB,5002867,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,38.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,38.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,39.888,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,27,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,38.728,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,27,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,38.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,38.728,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,38.728,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.168,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1828.488,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ZOVIRAX OINT 15GM,5003003,CDM,270,RC,,,Outpatient,,,352.00,352.00,,206.8,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,206.8,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,170.4,48.41,,142.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,316.8,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,316.8,90,,1941.84,Percent of Total Billed Charges,90% of Total Billed Charges,165.44,47,,137.992,Percent of Total Billed Charges,47% of Total Billed Charges,316.8,90,,1941.84,Percent of Total Billed Charges,90% of Total Billed Charges,206.8,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,165.44,47,,137.992,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,165.44,47,,137.992,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,165.44,47,,1828.488,Percent of Total Billed Charges,47% of Total Billed Charges,165.44,47,,1447.6,Percent of Total Billed Charges,47% of Total Billed Charges,165.44,316.8,
AMOXIL 125 150ML,5003016,CDM,259,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,1447.6,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,109.416,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
AMOXILI-250 -150ML,5003021,CDM,259,RC,,,Outpatient,,,33.00,33.00,,19.39,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.39,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.98,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,29.7,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,29.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,15.51,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,29.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,19.39,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.51,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,109.416,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,47,,93.624,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,29.7,
BACTROBAN OINT 15GM,5003050,CDM,270,RC,,,Outpatient,,,222.00,222.00,,130.43,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,130.43,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,107.47,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,199.8,90,,58.608,Percent of Total Billed Charges,90% of Total Billed Charges,199.8,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,104.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,199.8,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,130.43,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,104.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,104.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,104.34,47,,93.624,Percent of Total Billed Charges,47% of Total Billed Charges,104.34,47,,139.872,Percent of Total Billed Charges,47% of Total Billed Charges,104.34,199.8,
ZESTRIL 10MG,5003057,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,256.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,256.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,139.872,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
ZOCOR 10MG,5003058,CDM,259,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,37.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,36.848,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,14.104,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
DEBROX 15ML OTIC,5003069,CDM,259,RC,,,Outpatient,,,29.00,29.00,,17.04,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.04,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.04,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,26.1,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,26.1,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,13.63,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,26.1,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,17.04,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.63,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.63,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.63,47,,14.104,Percent of Total Billed Charges,47% of Total Billed Charges,13.63,47,,1014.072,Percent of Total Billed Charges,47% of Total Billed Charges,13.63,26.1,
GENTAMYCIN 80MGH,5003072,CDM,250,RC,,,Outpatient,,,31.90,31.90,,18.74,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.74,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.44,48.41,,27.496,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.71,90,,156.96,Percent of Total Billed Charges,90% of Total Billed Charges,28.71,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,14.99,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,28.71,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,18.74,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.99,47,,26.696,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.99,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.99,47,,1014.072,Percent of Total Billed Charges,47% of Total Billed Charges,14.99,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,14.99,28.71,
CEFZIL 250MG/5ML(50),5003077,CDM,259,RC,,,Outpatient,,,221.50,221.50,,130.13,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,130.13,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,107.23,48.41,,27.496,Percent of Total Billed Charges,48.41% of Total Billed Charges,199.35,90,,126.72,Percent of Total Billed Charges,90% of Total Billed Charges,199.35,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,104.11,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,199.35,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,130.13,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,104.11,47,,26.696,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,104.11,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,104.11,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,104.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,104.11,199.35,
CEPHALEXIN 125MG 5ML,5003092,CDM,259,RC,,,Outpatient,,,66.00,66.00,,38.78,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.78,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.95,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,59.4,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,59.4,90,,58.608,Percent of Total Billed Charges,90% of Total Billed Charges,31.02,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,59.4,90,,58.608,Percent of Total Billed Charges,90% of Total Billed Charges,38.78,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.02,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.02,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.02,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,31.02,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,31.02,59.4,
KEFLEX 125MG/5ML 5ML,5003094,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,133.856,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
KEFLEX 250 MG O,5003097,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,68.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,82.08,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,66.928,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,66.928,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,66.928,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,133.856,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
KEFLEX 250/100ML,5003098,CDM,259,RC,,,Outpatient,,,104.00,104.00,,61.1,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.1,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.35,48.41,,81.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,93.6,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,93.6,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,48.88,47,,79.336,Percent of Total Billed Charges,47% of Total Billed Charges,93.6,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,61.1,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.88,47,,79.336,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,48.88,47,,79.336,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.88,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,48.88,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,48.88,93.6,
KCL LIQ DOSE,5003099,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,156.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,156.96,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
KCL INJ,5003100,CDM,250,RC,,,Outpatient,,,20.90,20.90,,12.28,58.75,,34.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.28,58.75,,34.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.12,48.41,,8.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.81,90,,143.352,Percent of Total Billed Charges,90% of Total Billed Charges,18.81,90,,126.72,Percent of Total Billed Charges,90% of Total Billed Charges,9.82,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,18.81,90,,126.72,Percent of Total Billed Charges,90% of Total Billed Charges,12.28,58.75,,34.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,8.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.82,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,18.81,
CEPHALEXIN 250/5ML,5003101,CDM,259,RC,,,Outpatient,,,104.00,104.00,,61.1,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.1,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.35,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,93.6,90,,1897.92,Percent of Total Billed Charges,90% of Total Billed Charges,93.6,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,48.88,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,93.6,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,61.1,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.88,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,48.88,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.88,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,48.88,47,,30.608,Percent of Total Billed Charges,47% of Total Billed Charges,48.88,93.6,
CEPHALEXIN 500MG O,5003110,CDM,259,RC,,,Outpatient,,,12.00,12.00,,7.05,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,139.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,70.56,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,135.36,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,135.36,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,135.36,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,30.608,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
CEPACOL M/W 6OZL,5003112,CDM,259,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,29.824,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,130.32,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,82.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,28.952,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,82.08,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,28.952,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,28.952,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
CHLORPROPAMIDE 250MG,5003113,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
HIBICLENS 4OZ D,5003127,CDM,259,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,10.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,10.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,81.968,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
HIBICLENS 8OZ D,5003128,CDM,259,RC,,,Outpatient,,,28.00,28.00,,16.45,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.2,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,90,,143.352,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,25.2,90,,143.352,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,81.968,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,47,,66.176,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,25.2,
CLEOCIN 150 INJ,5003138,CDM,250,RC,,,Outpatient,,,25.00,25.00,,14.69,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.69,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.1,48.41,,11.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.5,90,,17717.76,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,90,,1897.92,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,22.5,90,,1897.92,Percent of Total Billed Charges,90% of Total Billed Charges,14.69,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,11.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.75,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,66.176,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,22.5,
CELOCIN/CLINDAMY.150,5003140,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,40.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,40.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,70.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,70.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,40.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CLEOCIN 150 MG CAP,5003141,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,14.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,209.52,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,130.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,130.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,13.912,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,42.864,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
LOTRIMIN CR 1% 15GM,5003144,CDM,270,RC,,,Outpatient,,,35.00,35.00,,20.56,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.56,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.94,48.41,,3.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,31.5,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,31.5,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,31.5,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,20.56,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.45,47,,3.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.45,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.45,47,,42.864,Percent of Total Billed Charges,47% of Total Billed Charges,16.45,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,16.45,31.5,
LOTRIMIN SOLN 1,5003147,CDM,270,RC,,,Outpatient,,,32.00,32.00,,18.8,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,8.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.8,90,,47.52,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,15.04,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,28.8,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,8.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,28.8,
LOTRISONE CR 15GM,5003148,CDM,270,RC,,,Outpatient,,,129.00,129.00,,75.79,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.79,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.45,48.41,,61.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,116.1,90,,3229.2,Percent of Total Billed Charges,90% of Total Billed Charges,116.1,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,60.63,47,,60.16,Percent of Total Billed Charges,47% of Total Billed Charges,116.1,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,75.79,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,60.63,47,,60.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,60.63,47,,60.16,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,60.63,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,60.63,47,,74.864,Percent of Total Billed Charges,47% of Total Billed Charges,60.63,116.1,
GYNE LOTRIMIN 45GM,5003149,CDM,270,RC,,,Outpatient,,,81.00,81.00,,47.59,58.75,,28.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.59,58.75,,28.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.21,48.41,,8.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,72.9,90,,54.72,Percent of Total Billed Charges,90% of Total Billed Charges,72.9,90,,17717.76,Percent of Total Billed Charges,90% of Total Billed Charges,38.07,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,72.9,90,,17717.76,Percent of Total Billed Charges,90% of Total Billed Charges,47.59,58.75,,28.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.07,47,,8.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,38.07,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.07,47,,74.864,Percent of Total Billed Charges,47% of Total Billed Charges,38.07,47,,991.136,Percent of Total Billed Charges,47% of Total Billed Charges,38.07,72.9,
LOTRIMINVAG TAB,5003152,CDM,259,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,32.92,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,31.96,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,31.96,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,31.96,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,991.136,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
VIBRATABS 100MG,5003182,CDM,259,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,2696.4,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,209.52,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,209.52,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,68.056,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
VIBRAMYCIN 50MG,5003185,CDM,259,RC,,,Outpatient,,,9.00,9.00,,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.36,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.1,90,,3829.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,8.1,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.23,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,68.056,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,8.1,
E-MYCIN 333MG TAB,5003187,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,27.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,27.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3677.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,47.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,47.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,27.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ERYC 250MG CAP,5003188,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3229.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3229.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ERY-TAB 250MG,5003189,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,963.36,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,54.72,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,54.72,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,9252.608,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
IMDUR 30MG,5003198,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,105.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,13.464,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,102.648,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,102.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,102.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,9252.608,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
E E S -400 TAB O,5003213,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,68.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,68.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,14.832,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,2696.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,2696.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,68.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,109.416,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
IBUPROFEN 800MGO,5003223,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,10.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,84.744,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,3829.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,9.968,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,3829.68,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,9.968,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,9.968,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,109.416,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
GARAMYCIN CR/O 1% 15,5003237,CDM,270,RC,,,Outpatient,,,82.00,82.00,,48.18,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.18,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.7,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,73.8,90,,14.04,Percent of Total Billed Charges,90% of Total Billed Charges,73.8,90,,3677.04,Percent of Total Billed Charges,90% of Total Billed Charges,38.54,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,73.8,90,,3677.04,Percent of Total Billed Charges,90% of Total Billed Charges,48.18,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.54,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,38.54,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.54,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,38.54,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,38.54,73.8,
GARAMYCIN 1/8OZOINT,5003239,CDM,270,RC,,,Outpatient,,,82.00,82.00,,48.18,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.18,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.7,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,73.8,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,73.8,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,38.54,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,73.8,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,48.18,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.54,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,38.54,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.54,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,38.54,47,,1686.36,Percent of Total Billed Charges,47% of Total Billed Charges,38.54,73.8,
GENTAMICIN 20MG/2ML,5003243,CDM,250,RC,,,Outpatient,,,24.00,24.00,,14.1,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.1,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.62,48.41,,21.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.6,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,21.6,90,,963.36,Percent of Total Billed Charges,90% of Total Billed Charges,11.28,47,,21.096,Percent of Total Billed Charges,47% of Total Billed Charges,21.6,90,,963.36,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,21.096,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.28,47,,21.096,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,1686.36,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,47,,28.576,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,21.6,
GUIATUSS SYRUP 5ML,5003250,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,156.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,156.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,13.464,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,13.464,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,156.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,28.576,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,32.336,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
GYNE LOTRIM VAGTAB7,5003254,CDM,259,RC,,,Outpatient,,,82.00,82.00,,48.18,58.75,,48.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.18,58.75,,48.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.7,48.41,,19.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,73.8,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,73.8,90,,14.832,Percent of Total Billed Charges,90% of Total Billed Charges,38.54,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,73.8,90,,14.832,Percent of Total Billed Charges,90% of Total Billed Charges,48.18,58.75,,48.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.54,47,,19.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,38.54,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.54,47,,32.336,Percent of Total Billed Charges,47% of Total Billed Charges,38.54,47,,1408.12,Percent of Total Billed Charges,47% of Total Billed Charges,38.54,73.8,
PHISOHEX 5OZ D,5003264,CDM,259,RC,,,Outpatient,,,74.00,74.00,,43.48,58.75,,172.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,43.48,58.75,,172.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.82,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,66.6,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,66.6,90,,84.744,Percent of Total Billed Charges,90% of Total Billed Charges,34.78,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,66.6,90,,84.744,Percent of Total Billed Charges,90% of Total Billed Charges,43.48,58.75,,172.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,34.78,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,34.78,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,34.78,47,,1408.12,Percent of Total Billed Charges,47% of Total Billed Charges,34.78,47,,1999.944,Percent of Total Billed Charges,47% of Total Billed Charges,34.78,66.6,
HYDROGEN PEROX,5003271,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,14.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,14.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1999.944,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1920.232,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
HYDROGEN PEROX 16OZ,5003274,CDM,259,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,1920.232,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
IMIPRAMINE O,5003276,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,19.368,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,18.8,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,18.8,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,18.8,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,503.088,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
HYTRIN,5003277,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,69.84,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,503.088,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.032,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SSKI SOL DOSE,5003279,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.032,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.744,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
LUGOLS SOLUTION.5OZ,5003282,CDM,259,RC,,,Outpatient,,,18.00,18.00,,10.58,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.58,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.71,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.2,90,,35.64,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,8.46,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,16.2,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,10.58,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.46,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,7.744,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,47,,44.256,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,16.2,
ISOPTIN SR 240MG O,5003299,CDM,259,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,44.256,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,7.336,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
NIZORAL CREAM,5003301,CDM,270,RC,,,Outpatient,,,87.20,87.20,,51.23,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.23,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.21,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,78.48,90,,25.272,Percent of Total Billed Charges,90% of Total Billed Charges,78.48,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,40.98,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,78.48,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,51.23,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.98,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.98,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.98,47,,7.336,Percent of Total Billed Charges,47% of Total Billed Charges,40.98,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,40.98,78.48,
LEVSIN TAB,5003304,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,24.408,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
KWELL CREAM 2OZD,5003307,CDM,270,RC,,,Outpatient,,,37.00,37.00,,21.74,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.74,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.91,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,33.3,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,33.3,90,,69.84,Percent of Total Billed Charges,90% of Total Billed Charges,17.39,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,33.3,90,,69.84,Percent of Total Billed Charges,90% of Total Billed Charges,21.74,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.39,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.39,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.39,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,17.39,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,17.39,33.3,
KWELL LOTION 2OZ D,5003308,CDM,270,RC,,,Outpatient,,,32.00,32.00,,18.8,58.75,,83.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,83.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.8,90,,8096.256,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,15.04,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,28.8,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,58.75,,83.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,28.8,
KWELL SHAMPOO 2OZ D,5003309,CDM,270,RC,,,Outpatient,,,30.00,30.00,,17.63,58.75,,99.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.63,58.75,,99.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.52,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,27,90,,7.128,Percent of Total Billed Charges,90% of Total Billed Charges,27,90,,35.64,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,27,90,,35.64,Percent of Total Billed Charges,90% of Total Billed Charges,17.63,58.75,,99.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.1,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,27,
VERSED 2MG INJ,5003312,CDM,250,RC,,,Outpatient,,,60.50,60.50,,35.54,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.54,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.29,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,54.45,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,54.45,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,28.44,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,54.45,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,35.54,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.44,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.44,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.44,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,28.44,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,28.44,54.45,
MACROBID CAP,5003330,CDM,259,RC,,,Outpatient,,,27.00,27.00,,15.86,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.86,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.07,48.41,,11.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,24.3,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,24.3,90,,25.272,Percent of Total Billed Charges,90% of Total Billed Charges,12.69,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,24.3,90,,25.272,Percent of Total Billed Charges,90% of Total Billed Charges,15.86,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,11.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.69,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,24.3,
MAG OX 400MG,5003336,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,2.984,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,24.408,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,2.896,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,24.408,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.896,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,2.896,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
METRONIDAZ0LE 500MG,5003345,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,169.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,169.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,169.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,36.472,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MONISTAT 7 CR 45GM,5003351,CDM,259,RC,,,Outpatient,,,59.00,59.00,,34.66,58.75,,36.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.66,58.75,,36.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.56,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,53.1,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,53.1,90,,8096.256,Percent of Total Billed Charges,90% of Total Billed Charges,27.73,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,53.1,90,,8096.256,Percent of Total Billed Charges,90% of Total Billed Charges,34.66,58.75,,36.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.73,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,27.73,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.73,47,,36.472,Percent of Total Billed Charges,47% of Total Billed Charges,27.73,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,27.73,53.1,
MINOCIN 100MG,5003354,CDM,259,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,12.064,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,7.128,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,7.128,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,18.616,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
MINOCIN 50MG CAP O,5003355,CDM,259,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,9.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,9.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,18.616,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
NEOSPORIN OINT 15GM,5003390,CDM,270,RC,,,Outpatient,,,27.00,27.00,,15.86,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.86,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.07,48.41,,3.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,24.3,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,24.3,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,12.69,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,24.3,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,15.86,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,3.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.69,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,47,,13.2,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,24.3,
NEOSPORIN OO 1/8OZ,5003394,CDM,270,RC,,,Outpatient,,,145.00,145.00,,85.19,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,85.19,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,70.19,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,130.5,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,130.5,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,68.15,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,130.5,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,85.19,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,68.15,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,68.15,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,68.15,47,,13.2,Percent of Total Billed Charges,47% of Total Billed Charges,68.15,47,,12.744,Percent of Total Billed Charges,47% of Total Billed Charges,68.15,130.5,
NEOSPORIN-G CR 15GM,5003408,CDM,270,RC,,,Outpatient,,,29.00,29.00,,17.04,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.04,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.04,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,26.1,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,26.1,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.63,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,26.1,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,17.04,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.63,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.63,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.63,47,,12.744,Percent of Total Billed Charges,47% of Total Billed Charges,13.63,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,13.63,26.1,
MYCOLOG 15GM (GNRC),5003410,CDM,270,RC,,,Outpatient,,,18.00,18.00,,10.58,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.58,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.71,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.2,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,8.46,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,16.2,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,10.58,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.46,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,47,,4228.048,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,16.2,
E-MYCIN 250MG O,5003426,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,9.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,1620.72,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,12.064,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,12.064,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,9.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4228.048,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,3.72,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
NEOSPORIN PACKETT,5003433,CDM,270,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,20.52,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,3.72,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
CORTISPORIN O O,5003435,CDM,270,RC,,,Outpatient,,,333.00,333.00,,195.64,58.75,,75.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,195.64,58.75,,75.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,161.21,48.41,,37.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,299.7,90,,553.68,Percent of Total Billed Charges,90% of Total Billed Charges,299.7,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,156.51,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,299.7,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,195.64,58.75,,75.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,156.51,47,,36.848,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,156.51,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,156.51,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,156.51,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,156.51,299.7,
NEOSPORIN 10ML OS,5003444,CDM,270,RC,,,Outpatient,,,103.00,103.00,,60.51,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,60.51,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.86,48.41,,8.44,Percent of Total Billed Charges,48.41% of Total Billed Charges,92.7,90,,67.68,Percent of Total Billed Charges,90% of Total Billed Charges,92.7,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,48.41,47,,8.2,Percent of Total Billed Charges,47% of Total Billed Charges,92.7,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,60.51,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.41,47,,8.2,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,48.41,47,,8.2,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.41,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,48.41,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,48.41,92.7,
CORTISPORIN EAR10ML,5003445,CDM,259,RC,,,Outpatient,,,367.00,367.00,,215.61,58.75,,39.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,215.61,58.75,,39.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,177.66,48.41,,260.256,Percent of Total Billed Charges,48.41% of Total Billed Charges,330.3,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,330.3,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,172.49,47,,252.672,Percent of Total Billed Charges,47% of Total Billed Charges,330.3,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,215.61,58.75,,39.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,172.49,47,,252.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,172.49,47,,252.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,172.49,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,172.49,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,172.49,330.3,
MACRODANTIN 1`00MG,5003452,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,11.232,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,10.904,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
NITROFURANTOIN 100,5003453,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,82.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,1620.72,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,1620.72,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,6.296,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MACRODANTIN CAP50MG,5003454,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,20.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,20.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.296,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
NITROFURANTON 50MG,5003455,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,553.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,553.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
FORTAZ 2 GM IV,5003460,CDM,250,RC,,,Outpatient,,,98.00,98.00,,57.58,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.58,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.44,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,88.2,90,,229.68,Percent of Total Billed Charges,90% of Total Billed Charges,88.2,90,,67.68,Percent of Total Billed Charges,90% of Total Billed Charges,46.06,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,88.2,90,,67.68,Percent of Total Billed Charges,90% of Total Billed Charges,57.58,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.06,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,46.06,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.06,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,46.06,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,46.06,88.2,
NYSTATIN DOSE,5003467,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,128.312,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,128.312,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,180,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,128.312,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
NYSTAT SUSP 60ML BOT,5003468,CDM,259,RC,,,Outpatient,,,71.00,71.00,,41.71,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.71,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.37,48.41,,19.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,63.9,90,,84.96,Percent of Total Billed Charges,90% of Total Billed Charges,63.9,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,33.37,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,63.9,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,41.71,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.37,47,,19.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,33.37,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.37,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,33.37,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,33.37,63.9,
MYCOSTATIN BOTTLE,5003469,CDM,259,RC,,,Outpatient,,,71.00,71.00,,41.71,58.75,,12.456,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.71,58.75,,12.456,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.37,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,63.9,90,,123.84,Percent of Total Billed Charges,90% of Total Billed Charges,63.9,90,,82.8,Percent of Total Billed Charges,90% of Total Billed Charges,33.37,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,63.9,90,,82.8,Percent of Total Billed Charges,90% of Total Billed Charges,41.71,58.75,,12.456,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.37,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,33.37,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.37,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,33.37,47,,846.376,Percent of Total Billed Charges,47% of Total Billed Charges,33.37,63.9,
MYCOSTATIN OINT15GM,5003470,CDM,270,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,367.2,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,846.376,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,10.72,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
MYCOSTATIN VAG TAB,5003474,CDM,259,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,150.48,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,10.72,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,289.144,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
MYCOSTATIN VAG 15'S,5003475,CDM,259,RC,,,Outpatient,,,178.00,178.00,,104.58,58.75,,26.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,104.58,58.75,,26.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,86.17,48.41,,37.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,160.2,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,160.2,90,,229.68,Percent of Total Billed Charges,90% of Total Billed Charges,83.66,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,160.2,90,,229.68,Percent of Total Billed Charges,90% of Total Billed Charges,104.58,58.75,,26.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,83.66,47,,36.848,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,83.66,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,83.66,47,,289.144,Percent of Total Billed Charges,47% of Total Billed Charges,83.66,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,83.66,160.2,
TERAZOL VAG CR,5003488,CDM,270,RC,,,Outpatient,,,211.00,211.00,,123.96,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,123.96,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,102.15,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,189.9,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,189.9,90,,180,Percent of Total Billed Charges,90% of Total Billed Charges,99.17,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,189.9,90,,180,Percent of Total Billed Charges,90% of Total Billed Charges,123.96,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,99.17,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,99.17,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,99.17,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,99.17,47,,78.96,Percent of Total Billed Charges,47% of Total Billed Charges,99.17,189.9,
VANTIN 100MG TAB,5003521,CDM,259,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,284.4,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,84.96,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,84.96,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,78.96,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
PREP H OINT 1OZR,5003524,CDM,270,RC,,,Outpatient,,,23.00,23.00,,13.51,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.51,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.13,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.7,90,,287.28,Percent of Total Billed Charges,90% of Total Billed Charges,20.7,90,,123.84,Percent of Total Billed Charges,90% of Total Billed Charges,10.81,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,20.7,90,,123.84,Percent of Total Billed Charges,90% of Total Billed Charges,13.51,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.81,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,47,,43.24,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,20.7,
PREP H SUPP R,5003525,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,367.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,367.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,43.24,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
AEROBID INHALER,5003531,CDM,259,RC,,,Outpatient,,,360.00,360.00,,211.5,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,211.5,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,174.28,48.41,,3.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,324,90,,1483.2,Percent of Total Billed Charges,90% of Total Billed Charges,324,90,,150.48,Percent of Total Billed Charges,90% of Total Billed Charges,169.2,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,324,90,,150.48,Percent of Total Billed Charges,90% of Total Billed Charges,211.5,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,169.2,47,,3.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,169.2,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,169.2,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,169.2,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,169.2,324,
LIDOCAINE DRIP,5003536,CDM,250,RC,,,Outpatient,,,77.00,77.00,,45.24,58.75,,23.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.24,58.75,,23.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.28,48.41,,40.28,Percent of Total Billed Charges,48.41% of Total Billed Charges,69.3,90,,789.84,Percent of Total Billed Charges,90% of Total Billed Charges,69.3,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,36.19,47,,39.104,Percent of Total Billed Charges,47% of Total Billed Charges,69.3,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,45.24,58.75,,23.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,36.19,47,,39.104,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,36.19,47,,39.104,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,36.19,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,36.19,47,,119.944,Percent of Total Billed Charges,47% of Total Billed Charges,36.19,69.3,
PROCARDIA XL 90,5003537,CDM,259,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,119.944,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,94,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
BETADINE DOUCHEV,5003543,CDM,250,RC,,,Outpatient,,,27.00,27.00,,15.86,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.86,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.07,48.41,,9.8,Percent of Total Billed Charges,48.41% of Total Billed Charges,24.3,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,24.3,90,,284.4,Percent of Total Billed Charges,90% of Total Billed Charges,12.69,47,,9.512,Percent of Total Billed Charges,47% of Total Billed Charges,24.3,90,,284.4,Percent of Total Billed Charges,90% of Total Billed Charges,15.86,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,9.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.69,47,,9.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,94,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,47,,44.368,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,24.3,
BETADINE OINT 30GM,5003549,CDM,270,RC,,,Outpatient,,,32.00,32.00,,18.8,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.8,90,,346.32,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,90,,287.28,Percent of Total Billed Charges,90% of Total Billed Charges,15.04,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,28.8,90,,287.28,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,44.368,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,47,,64.672,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,28.8,
BETADINE SKIN CL 4OX,5003558,CDM,270,RC,,,Outpatient,,,30.00,30.00,,17.63,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.63,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.52,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,27,90,,2269.44,Percent of Total Billed Charges,90% of Total Billed Charges,27,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,27,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,17.63,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.1,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,64.672,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,47,,191.76,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,27,
BETADINE SOLN 4OZ,5003559,CDM,270,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,2898,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,1483.2,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,1483.2,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,191.76,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,78.584,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
BETADINE SOLN 8OZ D,5003560,CDM,270,RC,,,Outpatient,,,37.00,37.00,,21.74,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.74,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.91,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,33.3,90,,86.4,Percent of Total Billed Charges,90% of Total Billed Charges,33.3,90,,789.84,Percent of Total Billed Charges,90% of Total Billed Charges,17.39,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,33.3,90,,789.84,Percent of Total Billed Charges,90% of Total Billed Charges,21.74,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.39,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.39,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.39,47,,78.584,Percent of Total Billed Charges,47% of Total Billed Charges,17.39,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,17.39,33.3,
RIFAMPIN 300MG O,5003586,CDM,259,RC,,,Outpatient,,,9.00,9.00,,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.36,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.1,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,8.1,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.23,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,8.1,
SIVADENE CR 1 OZ,5003600,CDM,270,RC,,,Outpatient,,,23.00,23.00,,13.51,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.51,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.13,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.7,90,,5616,Percent of Total Billed Charges,90% of Total Billed Charges,20.7,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,10.81,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,20.7,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,13.51,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.81,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,47,,148.52,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,20.7,
SILVADENE CR 400GM,5003603,CDM,270,RC,,,Outpatient,,,160.00,160.00,,94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,77.46,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,144,90,,1653.12,Percent of Total Billed Charges,90% of Total Billed Charges,144,90,,346.32,Percent of Total Billed Charges,90% of Total Billed Charges,75.2,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,144,90,,346.32,Percent of Total Billed Charges,90% of Total Billed Charges,94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,75.2,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,75.2,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,75.2,47,,148.52,Percent of Total Billed Charges,47% of Total Billed Charges,75.2,47,,150.024,Percent of Total Billed Charges,47% of Total Billed Charges,75.2,144,
SILVADENE CR 1 OZ,5003604,CDM,270,RC,,,Outpatient,,,23.00,23.00,,13.51,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.51,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.13,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.7,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,20.7,90,,2269.44,Percent of Total Billed Charges,90% of Total Billed Charges,10.81,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,20.7,90,,2269.44,Percent of Total Billed Charges,90% of Total Billed Charges,13.51,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.81,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,150.024,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,20.7,
SULAMYD,5003608,CDM,270,RC,,,Outpatient,,,85.00,85.00,,49.94,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.94,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.15,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,76.5,90,,714.24,Percent of Total Billed Charges,90% of Total Billed Charges,76.5,90,,2898,Percent of Total Billed Charges,90% of Total Billed Charges,39.95,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,76.5,90,,2898,Percent of Total Billed Charges,90% of Total Billed Charges,49.94,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,39.95,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,39.95,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,39.95,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,39.95,47,,774.56,Percent of Total Billed Charges,47% of Total Billed Charges,39.95,76.5,
AUGMENTIN 500MGTAB,5003645,CDM,259,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,3.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,3.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,653.76,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,86.4,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,86.4,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,3.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,774.56,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,412.472,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
AUGMENTIN 250MGTAB,5003648,CDM,259,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,3.288,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,1295.28,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,3.2,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,3.2,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,3.2,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,412.472,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
GLYNASE 6MG TAB,5003659,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,5616,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,5616,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TETRACYCLINE 250MG,5003669,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,1653.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,1653.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,180.856,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TETRACYCLINE 500MG,5003671,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,85.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,180.856,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1185.152,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
NASACORT INHALER,5003679,CDM,259,RC,,,Outpatient,,,273.00,273.00,,160.39,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,160.39,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,132.16,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,245.7,90,,51.84,Percent of Total Billed Charges,90% of Total Billed Charges,245.7,90,,714.24,Percent of Total Billed Charges,90% of Total Billed Charges,128.31,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,245.7,90,,714.24,Percent of Total Billed Charges,90% of Total Billed Charges,160.39,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,128.31,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,128.31,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,128.31,47,,1185.152,Percent of Total Billed Charges,47% of Total Billed Charges,128.31,47,,1513.4,Percent of Total Billed Charges,47% of Total Billed Charges,128.31,245.7,
MONOPRIL 10MG,5003688,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,653.76,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,653.76,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1513.4,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,45.12,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
IODOFORM GAUZE 1/2,5003709,CDM,270,RC,,,Outpatient,,,26.50,26.50,,15.57,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.57,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.83,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,23.85,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,23.85,90,,1295.28,Percent of Total Billed Charges,90% of Total Billed Charges,12.46,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,23.85,90,,1295.28,Percent of Total Billed Charges,90% of Total Billed Charges,15.57,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.46,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.46,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.46,47,,45.12,Percent of Total Billed Charges,47% of Total Billed Charges,12.46,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,12.46,23.85,
PROCARDIA XL 30MG,5003712,CDM,259,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,427.68,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,2932.8,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
SEPTRA O,5003713,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,9.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,9.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2932.8,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,863.296,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
BACTRIM SUSP 100ML,5003714,CDM,259,RC,,,Outpatient,,,56.10,56.10,,32.96,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.96,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.16,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,50.49,90,,85.536,Percent of Total Billed Charges,90% of Total Billed Charges,50.49,90,,85.68,Percent of Total Billed Charges,90% of Total Billed Charges,26.37,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,50.49,90,,85.68,Percent of Total Billed Charges,90% of Total Billed Charges,32.96,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.37,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.37,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.37,47,,863.296,Percent of Total Billed Charges,47% of Total Billed Charges,26.37,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,26.37,50.49,
BACTRIM SUSP 5ML L,5003715,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,51.84,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,51.84,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,372.992,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
SEPTRA SUSP 100ML,5003717,CDM,259,RC,,,Outpatient,,,51.00,51.00,,29.96,58.75,,10.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.96,58.75,,10.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.69,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,45.9,90,,7.128,Percent of Total Billed Charges,90% of Total Billed Charges,45.9,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,23.97,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,45.9,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,29.96,58.75,,10.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.97,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,372.992,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,47,,341.408,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,45.9,
SEPTRA SUSP 5 ML,5003718,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,315.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,315.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,26.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,315.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,25.944,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,341.408,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,676.424,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SEPTRA DS TABLET O,5003720,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,427.68,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,427.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,676.424,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
ULTRAM 50MG TAB,5003733,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,142.56,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
VANCOMYCIN 500MG INJ,5003736,CDM,250,RC,,,Outpatient,,,50.00,50.00,,29.38,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.38,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.21,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,45,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,45,90,,85.536,Percent of Total Billed Charges,90% of Total Billed Charges,23.5,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,45,90,,85.536,Percent of Total Billed Charges,90% of Total Billed Charges,29.38,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.5,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.5,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.5,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,23.5,47,,44.744,Percent of Total Billed Charges,47% of Total Billed Charges,23.5,45,
AMOXICILLIN 500MG CA,5004007,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,44.744,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,27.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
AMOXICILLIN 250MG CA,5004009,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,7.128,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,7.128,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,27.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
GAVISCON-2 TAB O,5004016,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,56.4,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
GAVISCON FOAM TABS O,5004017,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,56.4,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,223.344,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MAALOX NO 2 TAB,5004022,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,406.08,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,142.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,142.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,223.344,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ALTACE 10MG,5004023,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,125.28,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,44.672,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
MYLANTA II TABS,5004025,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,44.672,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MYLANTA TABLETS,5004026,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,3.72,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
GAVISCON LIQ 15ML L,5004027,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.72,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
GAVISCON LIQ 30ML L,5004028,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
GAVISCON LIQ 12OZ,5004029,CDM,259,RC,,,Outpatient,,,30.00,30.00,,17.63,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.63,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.52,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,27,90,,185.4,Percent of Total Billed Charges,90% of Total Billed Charges,27,90,,406.08,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,27,90,,406.08,Percent of Total Billed Charges,90% of Total Billed Charges,17.63,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.1,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,47,,74.448,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,27,
ALLEGRA CAP,5004032,CDM,259,RC,,,Outpatient,,,7.70,7.70,,4.52,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.52,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.73,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.93,90,,15.304,Percent of Total Billed Charges,90% of Total Billed Charges,6.93,90,,125.28,Percent of Total Billed Charges,90% of Total Billed Charges,3.62,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.93,90,,125.28,Percent of Total Billed Charges,90% of Total Billed Charges,4.52,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.62,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.62,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.62,47,,74.448,Percent of Total Billed Charges,47% of Total Billed Charges,3.62,47,,21.056,Percent of Total Billed Charges,47% of Total Billed Charges,3.62,6.93,
MAALOX 15ML,5004034,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,21.056,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DEMADEX 20MG TAB,5004036,CDM,259,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,48.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,48.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,48.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
MAALOX 30ML,5004037,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,37.224,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MAALOX SUSP 12OZ,5004038,CDM,259,RC,,,Outpatient,,,25.00,25.00,,14.69,58.75,,11.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.69,58.75,,11.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.1,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.5,90,,1.728,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,22.5,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,14.69,58.75,,11.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.75,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,37.224,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,22.5,
CALAN SR 180MG,5004046,CDM,259,RC,,,Outpatient,,,9.00,9.00,,5.29,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.29,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.36,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.1,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,90,,185.4,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,8.1,90,,185.4,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.23,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,47,,212.064,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,8.1,
MYLANTA 5OZ,5004048,CDM,259,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,10.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,15.304,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,15.304,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,9.776,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,212.064,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,65.424,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
GLYNASE 1.5MG TAB,5004050,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,11.232,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,10.904,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,65.424,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MYLANTA 30ML,5004051,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,24.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,24.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MYLANTA 12OZ,5004052,CDM,259,RC,,,Outpatient,,,25.00,25.00,,14.69,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.69,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.1,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.5,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,22.5,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,14.69,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.75,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,22.5,
MYLANTA II 30ML,5004058,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,1.728,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,1.728,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ANUSOL-HC CREAM30GM,5004077,CDM,270,RC,,,Outpatient,,,98.00,98.00,,57.58,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.58,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.44,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,88.2,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,88.2,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,46.06,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,88.2,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,57.58,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.06,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,46.06,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.06,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,46.06,47,,96.824,Percent of Total Billed Charges,47% of Total Billed Charges,46.06,88.2,
ANUSOL-HC SUPP R,5004078,CDM,259,RC,,,Outpatient,,,21.80,21.80,,12.81,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.81,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.55,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.62,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,19.62,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,10.25,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,19.62,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,12.81,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.25,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.25,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.25,47,,96.824,Percent of Total Billed Charges,47% of Total Billed Charges,10.25,47,,7.992,Percent of Total Billed Charges,47% of Total Billed Charges,10.25,19.62,
DONNATAL ELIX 4OZ,5004083,CDM,259,RC,,,Outpatient,,,672.00,672.00,,394.8,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,394.8,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,325.32,48.41,,12.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,604.8,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,604.8,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,315.84,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,604.8,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,394.8,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,315.84,47,,12.408,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,315.84,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,315.84,47,,7.992,Percent of Total Billed Charges,47% of Total Billed Charges,315.84,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,315.84,604.8,
DONNATAL ELIX 5ML,5004084,CDM,259,RC,,,Outpatient,,,29.00,29.00,,17.04,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.04,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.04,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,26.1,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,26.1,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,13.63,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,26.1,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,17.04,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.63,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.63,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.63,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,13.63,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,13.63,26.1,
URISED TAB,5004088,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,21.056,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DONNATAL TABLET,5004092,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,17.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,16.92,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,21.056,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,0.904,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
BISACODYL TAB 5MG,5004105,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,0.904,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
BISACODYL SUPP 10MG,5004109,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
PEPCID 40MG TABLET,5004115,CDM,259,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
MONISTAT 3 SUPP,5004135,CDM,259,RC,,,Outpatient,,,51.00,51.00,,29.96,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.96,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.69,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,45.9,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,45.9,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,23.97,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,45.9,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,29.96,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.97,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,45.9,
CASCARA 5ML L,5004137,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
CASTOR OIL 5ML,5004138,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,13.944,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,13.536,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CASTOR OIL 60MLL,5004139,CDM,259,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,12.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,12.408,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
ACTIVATED CHAR 25GM,5004146,CDM,250,RC,,,Outpatient,,,98.00,98.00,,57.58,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.58,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.44,48.41,,3.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,88.2,90,,69.84,Percent of Total Billed Charges,90% of Total Billed Charges,88.2,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,46.06,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,88.2,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,57.58,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.06,47,,3.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,46.06,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.06,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,46.06,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,46.06,88.2,
LIBRAX,5004153,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
DICYCLOMINE 10MG O,5004172,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DICYCLOMINE 20MG O,5004173,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
LOMOTIL 2.5MG,5004189,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
LOMOTIL LIQ 5 ML,5004193,CDM,259,RC,,,Outpatient,,,9.00,9.00,,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.36,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.1,90,,172.08,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,8.1,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.23,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,8.1,
LOMOTIL LIQ 2OZ,5004194,CDM,259,RC,,,Outpatient,,,104.00,104.00,,61.1,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.1,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.35,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,93.6,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,93.6,90,,69.84,Percent of Total Billed Charges,90% of Total Billed Charges,48.88,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,93.6,90,,69.84,Percent of Total Billed Charges,90% of Total Billed Charges,61.1,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.88,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,48.88,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.88,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,48.88,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,48.88,93.6,
COLACE 100MG CAP O D,5004195,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
COLACE LIQ 30ML,5004200,CDM,259,RC,,,Outpatient,,,25.30,25.30,,14.86,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.86,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.25,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.77,90,,4.752,Percent of Total Billed Charges,90% of Total Billed Charges,22.77,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,11.89,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,22.77,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,14.86,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.89,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.89,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.89,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,11.89,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,11.89,22.77,
COLACE 5ML SYRUP L,5004203,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,31.76,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,30.832,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
SURFAK 240MG O,5004205,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,34.08,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,33.088,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,33.088,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,33.088,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DIALOSE PLUS O,5004213,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,40.28,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,172.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,39.104,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,172.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,39.104,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,39.104,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
COLACE PLUS,5004214,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,36.472,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
PERI-COLACE 30ML,5004216,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,1.584,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,36.472,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
PERI-COLACE SYR5ML,5004217,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,17.424,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,4.752,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,4.752,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
FLAGYL 500MG ORAL,5004225,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,9.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,9.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
RISPERDAL 1MG,5004227,CDM,259,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,11.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,3.168,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,11.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
GLYCERIN ADULT SUPP,5004229,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,9.296,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,9.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,89.864,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
GLYCERIN CHILD SUPP,5004230,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,29.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,28.2,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,89.864,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
ANAPROX DS TAB,5004249,CDM,259,RC,,,Outpatient,,,8.50,8.50,,4.99,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.99,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,48.41,,62.352,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.65,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,7.65,90,,1.584,Percent of Total Billed Charges,90% of Total Billed Charges,4,47,,60.536,Percent of Total Billed Charges,47% of Total Billed Charges,7.65,90,,1.584,Percent of Total Billed Charges,90% of Total Billed Charges,4.99,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4,47,,60.536,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4,47,,60.536,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,4,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,4,7.65,
IPECA SYRUP 30ML L,5004254,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,17.424,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,17.424,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.48,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
KAOPECTATE LIQ 90ML,5004264,CDM,259,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,2.48,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
KAOPECTATE CON DOSE,5004265,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,38.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.168,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.168,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,37.6,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
KAOPECTATE CONC30ML,5004266,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,15.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,15.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
KAOPECTATE CONC60ML,5004267,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,15.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,15.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
LANOXIN 0.125 MG TAB,5004284,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,25.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,855.36,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,24.816,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,0.824,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
LACTINEX TABLET,5004285,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,22.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,11.088,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,21.432,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,0.824,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,9.096,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CIPRO 750MG TAB,5004288,CDM,259,RC,,,Outpatient,,,25.00,25.00,,14.69,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.69,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.1,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.5,90,,66.24,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,22.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,14.69,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.75,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,9.096,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,22.5,
LACTULOSE SYRUP15ML,5004289,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,1.656,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
IMODIUM 2MG CAPO,5004293,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,28.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,36,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,27.824,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,27.824,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,27.824,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.656,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
CITRATE MAG 300ML L,5004294,CDM,259,RC,,,Outpatient,,,12.00,12.00,,7.05,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,3.456,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
ERYTHROMYCIN OPH-OIN,5004308,CDM,270,RC,,,Outpatient,,,69.00,69.00,,40.54,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.54,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.4,48.41,,73.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,62.1,90,,22.32,Percent of Total Billed Charges,90% of Total Billed Charges,62.1,90,,855.36,Percent of Total Billed Charges,90% of Total Billed Charges,32.43,47,,71.44,Percent of Total Billed Charges,47% of Total Billed Charges,62.1,90,,855.36,Percent of Total Billed Charges,90% of Total Billed Charges,40.54,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.43,47,,71.44,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,32.43,47,,71.44,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.43,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,32.43,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,32.43,62.1,
REMERON 15MG TAB,5004312,CDM,259,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,16.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,11.088,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,11.088,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,15.792,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,1.504,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
RIOPAN LIQ 15MLL,5004313,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,66.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,66.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.504,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
RIOPAN 30ML L,5004314,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,21.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,21.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,21.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.504,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PAXIL 20MG,5004322,CDM,259,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,36,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,36,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,1.504,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
METOCLOPRAMIDE 10MG,5004326,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,72.72,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,3.456,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,3.456,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
MOM 30ML,5004328,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,22.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,22.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,446.688,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
MOM W/CASARA #)ML,5004330,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,446.688,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,5.792,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MINERAL OIL 30ML,5004333,CDM,259,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,5.792,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,34.592,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
FLEET OIL ENEMAR,5004344,CDM,259,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,137.016,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,34.592,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
MINERAL OIL ST 30ML,5004347,CDM,259,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,56.88,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,18.8,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
OXYCONTIN 20MGMG TAB,5004366,CDM,259,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,16.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,74.448,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,72.72,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,72.72,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,15.792,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,18.8,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,1.808,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
OXYBUTYNIN 5MG TAB,5004368,CDM,259,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,90.288,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,1.808,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,11.656,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
TRAZADONE 150MG,5004376,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,11.656,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,18.048,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PANCOF HC 5ML,5004383,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,30.096,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,18.048,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
EX-LAX TAB O,5004389,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,137.016,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,137.016,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
GUIATUSS DM SYR4 OZ,5004390,CDM,259,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,56.88,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,56.88,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,56.88,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
COMPAZINE 10MG O,5004397,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,74.448,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,74.448,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,37.976,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
COMPAZINE 25MG O,5004399,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,20.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,90.288,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,90.288,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,19.552,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,37.976,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
COMPAZINE 5MG O,5004401,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
COMPAZINE 25MG SUPP,5004405,CDM,259,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,5.544,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,30.096,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,30.096,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
PHENERGAN SUPP 12.5,5004406,CDM,259,RC,,,Outpatient,,,26.00,26.00,,15.28,58.75,,41.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.28,58.75,,41.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.59,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,23.4,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,23.4,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,12.22,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,23.4,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,15.28,58.75,,41.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.22,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.22,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.22,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,12.22,47,,71.552,Percent of Total Billed Charges,47% of Total Billed Charges,12.22,23.4,
PHENERGAN SUPP 25MG,5004407,CDM,259,RC,,,Outpatient,,,29.00,29.00,,17.04,58.75,,48.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.04,58.75,,48.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.04,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,26.1,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,26.1,90,,56.88,Percent of Total Billed Charges,90% of Total Billed Charges,13.63,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,26.1,90,,56.88,Percent of Total Billed Charges,90% of Total Billed Charges,17.04,58.75,,48.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.63,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.63,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.63,47,,71.552,Percent of Total Billed Charges,47% of Total Billed Charges,13.63,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,13.63,26.1,
PHENERGAN SUPP 50MG,5004408,CDM,259,RC,,,Outpatient,,,64.00,64.00,,37.6,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.6,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.98,48.41,,13.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,57.6,90,,29.52,Percent of Total Billed Charges,90% of Total Billed Charges,57.6,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,30.08,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,57.6,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,37.6,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.08,47,,13.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,30.08,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.08,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,30.08,47,,38.88,Percent of Total Billed Charges,47% of Total Billed Charges,30.08,57.6,
PREMARIN 0.3 MGTAB,5004409,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,20.024,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,149.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,19.44,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,19.44,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,19.44,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,38.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,47.152,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PRINIVIL 10MG,5004411,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,18.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,17.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,47.152,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
METAMUCIL IN MIX,5004421,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,53.448,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,5.544,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,51.888,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,5.544,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,51.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,51.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,15.72,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
PERCOCET TAB,5004435,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,48.8,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,47.376,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,15.72,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
ZYPREZIA 5MG,5004440,CDM,250,RC,,,Outpatient,,,33.00,33.00,,19.39,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.39,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.98,48.41,,17.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,29.7,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,29.7,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,15.51,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,29.7,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,19.39,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,17.296,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.51,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,29.7,
MYLICON 40MG,5004452,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,1.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,29.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,29.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MYLICON 80MG,5004455,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,75.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,75.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,30.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,149.76,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,149.76,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,75.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,29.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MYLICON DROPS 30ML,5004457,CDM,259,RC,,,Outpatient,,,45.00,45.00,,26.44,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,26.44,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.78,48.41,,36.792,Percent of Total Billed Charges,48.41% of Total Billed Charges,40.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,47,,35.72,Percent of Total Billed Charges,47% of Total Billed Charges,40.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,26.44,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.15,47,,35.72,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,21.15,47,,35.72,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.15,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,21.15,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,21.15,40.5,
SOD BICARBONATEO,5004459,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,61.192,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,59.408,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,59.408,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,59.408,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.896,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
COMPAZINE 25MG SUPP,5004462,CDM,259,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,2.896,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
FLEET ENEMA REGULAR,5004463,CDM,259,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,67.68,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
FLEET ENEMA PEDI R,5004464,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,1.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,1.8,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,15.416,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
CARAFATE 1GM TAB,5004467,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,15.416,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,78.208,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
TORADOL 60MG INJ,5004468,CDM,250,RC,,,Outpatient,,,36.00,36.00,,21.15,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.15,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.43,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,32.4,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,32.4,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,16.92,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,32.4,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.92,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.92,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.92,47,,78.208,Percent of Total Billed Charges,47% of Total Billed Charges,16.92,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,16.92,32.4,
TORADOL 30MG INJ,5004471,CDM,250,RC,,,Outpatient,,,33.00,33.00,,19.39,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.39,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.98,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,29.7,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,29.7,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,15.51,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,29.7,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,19.39,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.51,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,29.7,
COZAAR 50MG,5004493,CDM,259,RC,,,Outpatient,,,10.00,10.00,,5.88,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.88,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.84,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,9,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,9,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,9,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,5.88,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.7,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,9,
ALTACE 2.5MG CAP,5004504,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,34.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,34.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,90.72,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,67.68,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,67.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,34.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
LORTAB 7.5,5004505,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,42.48,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,0.944,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
RIOPAN PLUS 15ML L,5004509,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,89.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,89.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,89.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,0.944,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
RIOPAN PLUS 30ML L,5004510,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,19.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,19.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,19.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
FLEET PHOS-SODA1.5,5004512,CDM,259,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
MAALOX T.C. 15ML,5004514,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MAALOX T.C. 30ML,5004515,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,51.12,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,41.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,90.72,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,49.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,90.72,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,49.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,49.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
PHAZYME,5004522,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,4.688,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,42.48,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.552,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,42.48,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.552,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.552,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MAXALT 10MG TAB,5005014,CDM,259,RC,,,Outpatient,,,82.00,82.00,,48.18,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.18,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.7,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,73.8,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,73.8,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,38.54,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,73.8,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,48.18,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.54,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,38.54,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.54,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,38.54,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,38.54,73.8,
VOSOL HC OTIC OS,5006002,CDM,259,RC,,,Outpatient,,,88.00,88.00,,51.7,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.7,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.6,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,79.2,90,,45.936,Percent of Total Billed Charges,90% of Total Billed Charges,79.2,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,41.36,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,79.2,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,51.7,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,41.36,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,41.36,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,41.36,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,41.36,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,41.36,79.2,
TOPICORT .25% 15GM,5006048,CDM,270,RC,,,Outpatient,,,104.00,104.00,,61.1,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.1,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.35,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,93.6,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,93.6,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,48.88,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,93.6,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,61.1,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.88,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,48.88,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.88,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,48.88,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,48.88,93.6,
DECADRON 4.0MG O,5006054,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,46.864,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,45.496,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,45.496,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,45.496,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
DEXAMETHASONE ELIX,5006060,CDM,259,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,41.76,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,41.76,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
DEXAMETHASONE 5ML EL,5006061,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,19.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,19.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,104.4,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,19.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,22.184,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DECADRON .05% 3.5GM,5006063,CDM,270,RC,,,Outpatient,,,25.00,25.00,,14.69,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.69,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.1,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,22.5,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,14.69,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.75,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,22.184,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,22.5,
DECADRON .1% 2.5ML O,5006065,CDM,259,RC,,,Outpatient,,,30.00,30.00,,17.63,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.63,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.52,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,27,90,,77.04,Percent of Total Billed Charges,90% of Total Billed Charges,27,90,,45.936,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,27,90,,45.936,Percent of Total Billed Charges,90% of Total Billed Charges,17.63,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.1,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,27,
NEO-DECADRON OO,5006068,CDM,250,RC,,,Outpatient,,,24.00,24.00,,14.1,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.1,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.62,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.6,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,21.6,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,11.28,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,21.6,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.28,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,21.6,
NEO-DECAD OPTH SOL B,5006069,CDM,259,RC,,,Outpatient,,,75.00,75.00,,44.06,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.06,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.31,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,67.5,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,35.25,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,67.5,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,44.06,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.25,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,35.25,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.25,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,35.25,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,35.25,67.5,
MAXITROL 5CC OS,5006070,CDM,259,RC,,,Outpatient,,,161.00,161.00,,94.59,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,94.59,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,77.94,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,144.9,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,144.9,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,75.67,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,144.9,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,94.59,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,75.67,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,75.67,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,75.67,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,75.67,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,75.67,144.9,
FUROSEMIDE 40MGO,5006071,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,54.328,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,104.4,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,104.4,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
FUROSEMIDE 20MGTAB,5006072,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,24.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,24.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,24.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
SYNALAR-HP CR 12GM D,5006086,CDM,270,RC,,,Outpatient,,,100.00,100.00,,58.75,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.75,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.41,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,90,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,90,90,,77.04,Percent of Total Billed Charges,90% of Total Billed Charges,47,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,90,90,,77.04,Percent of Total Billed Charges,90% of Total Billed Charges,58.75,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,47,47,,23.992,Percent of Total Billed Charges,47% of Total Billed Charges,47,90,
SYNALAR CR .01%15GM,5006087,CDM,270,RC,,,Outpatient,,,40.00,40.00,,23.5,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.5,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.36,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,36,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,36,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,36,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,23.5,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.8,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,23.992,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,36,
SYNALAR .025% 15GM,5006088,CDM,270,RC,,,Outpatient,,,40.00,40.00,,23.5,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.5,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.36,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,36,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,36,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,36,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,23.5,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.8,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,36,
SYNALAR SOLN 20ML O,5006092,CDM,259,RC,,,Outpatient,,,66.00,66.00,,38.78,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.78,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.95,48.41,,3.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,59.4,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,59.4,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,31.02,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,59.4,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,38.78,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.02,47,,3.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.02,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.02,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,31.02,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,31.02,59.4,
LIDEX CR .05% 15GM,5006094,CDM,270,RC,,,Outpatient,,,57.00,57.00,,33.49,58.75,,16.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.49,58.75,,16.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.59,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,51.3,90,,59.76,Percent of Total Billed Charges,90% of Total Billed Charges,51.3,90,,54.328,Percent of Total Billed Charges,90% of Total Billed Charges,26.79,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,51.3,90,,54.328,Percent of Total Billed Charges,90% of Total Billed Charges,33.49,58.75,,16.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.79,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,26.79,47,,54.52,Percent of Total Billed Charges,47% of Total Billed Charges,26.79,51.3,
TOLUSED/TOL-DM DOSE,5006097,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,24.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,24.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,24.296,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,54.52,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
HYDRALAZINE 50MG O,5006138,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,40.232,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CORTANE B OTIC 10ML,5006139,CDM,259,RC,,,Outpatient,,,74.00,74.00,,43.48,58.75,,64.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,43.48,58.75,,64.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.82,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,66.6,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,66.6,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,34.78,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,66.6,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,43.48,58.75,,64.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,34.78,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,34.78,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,34.78,47,,40.232,Percent of Total Billed Charges,47% of Total Billed Charges,34.78,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,34.78,66.6,
HYDROCORT CR 1%30,5006142,CDM,270,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
PROTOFOAMHC 15GM R,5006146,CDM,259,RC,,,Outpatient,,,190.00,190.00,,111.63,58.75,,21.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,111.63,58.75,,21.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,91.98,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,171,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,171,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,89.3,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,171,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,111.63,58.75,,21.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,89.3,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,89.3,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,89.3,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,89.3,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,89.3,171,
HYDROCORT CR 2.5%,5006149,CDM,270,RC,,,Outpatient,,,42.00,42.00,,24.68,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.68,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.33,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,37.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,37.8,90,,59.76,Percent of Total Billed Charges,90% of Total Billed Charges,19.74,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,37.8,90,,59.76,Percent of Total Billed Charges,90% of Total Billed Charges,24.68,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.74,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,19.74,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.74,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,19.74,47,,28.368,Percent of Total Billed Charges,47% of Total Billed Charges,19.74,37.8,
MOTRIN 200MG,5006168,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,106.704,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,28.368,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
MOTRIN 400MG,5006169,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,44.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,44.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,44.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
MOTRIN 600MG TAB,5006170,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,74.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,74.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,28.08,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,74.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
INDOMETHACIN 25MG O,5006172,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
INDOMETHACIN 50MG O,5006173,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,23.688,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
GYNE LOTRIMIN VAG TA,5006179,CDM,259,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,23.688,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,31.208,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
MEDROL 16MG,5006186,CDM,259,RC,,,Outpatient,,,12.00,12.00,,7.05,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,106.704,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,106.704,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,31.208,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
MEDROL 2MG TAB,5006188,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MEDROL 4MG,5006190,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,26.136,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,28.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,28.08,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
MEDROL ENPAK REFILL,5006193,CDM,259,RC,,,Outpatient,,,42.00,42.00,,24.68,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.68,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.33,48.41,,10.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,37.8,90,,163.44,Percent of Total Billed Charges,90% of Total Billed Charges,37.8,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,19.74,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,37.8,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,24.68,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.74,47,,10.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,19.74,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.74,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,19.74,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,19.74,37.8,
NAPROXEN 250MG,5006194,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
NAPROXEN 375MG TAB,5006196,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,199.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
NAPROXEN 500MG TAB,5006197,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,55.72,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
BUSPAR 15MG,5006202,CDM,259,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,77.04,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,55.72,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
PREDNISONE SYRUP 5ML,5006210,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,26.136,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,26.136,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,14.664,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
PREDNISONE SYRP40Z,5006214,CDM,259,RC,,,Outpatient,,,28.00,28.00,,16.45,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.2,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,90,,163.44,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,25.2,90,,163.44,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,14.664,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,25.2,
PRED FORTE 5ML 1% OS,5006216,CDM,259,RC,,,Outpatient,,,52.00,52.00,,30.55,58.75,,62.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.55,58.75,,62.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.17,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,46.8,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,46.8,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,24.44,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,46.8,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,30.55,58.75,,62.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.44,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,24.44,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.44,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,24.44,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,24.44,46.8,
PREDISONE 10MG,5006225,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,5.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,5.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,199.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,199.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,5.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PREDNISONE 20MG,5006228,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,14.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,14.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
PREDNISONE 50MG,5006230,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,185.4,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,77.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,77.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PREDNISONE 5MG,5006231,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,9.576,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,13.648,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ARICEPT 5MG TAB,5006241,CDM,259,RC,,,Outpatient,,,35.00,35.00,,20.56,58.75,,56.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.56,58.75,,56.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.94,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,31.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,31.5,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,31.5,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,20.56,58.75,,56.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.45,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.45,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.45,47,,13.648,Percent of Total Billed Charges,47% of Total Billed Charges,16.45,47,,85.352,Percent of Total Billed Charges,47% of Total Billed Charges,16.45,31.5,
TRIAMCINOLONE .1% CR,5006250,CDM,270,RC,,,Outpatient,,,51.70,51.70,,30.37,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.37,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.03,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,46.53,90,,35.28,Percent of Total Billed Charges,90% of Total Billed Charges,46.53,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,24.3,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,46.53,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,30.37,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.3,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,24.3,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.3,47,,85.352,Percent of Total Billed Charges,47% of Total Billed Charges,24.3,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,24.3,46.53,
ARISTOCORT .1% 15GM,5006254,CDM,270,RC,,,Outpatient,,,47.00,47.00,,27.61,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.61,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.75,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,42.3,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,22.09,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,42.3,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,27.61,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,22.09,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,47,,104.152,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,42.3,
ARISTOCORT .5% 15GM,5006257,CDM,270,RC,,,Outpatient,,,138.00,138.00,,81.08,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,81.08,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.81,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,124.2,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,124.2,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,64.86,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,124.2,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,81.08,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,64.86,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,64.86,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,64.86,47,,104.152,Percent of Total Billed Charges,47% of Total Billed Charges,64.86,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,64.86,124.2,
KENALOG SPRAY 23GM,5006270,CDM,259,RC,,,Outpatient,,,126.00,126.00,,74.03,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.03,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,61,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,113.4,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,113.4,90,,185.4,Percent of Total Billed Charges,90% of Total Billed Charges,59.22,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,113.4,90,,185.4,Percent of Total Billed Charges,90% of Total Billed Charges,74.03,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,59.22,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,59.22,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,59.22,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,59.22,47,,40.232,Percent of Total Billed Charges,47% of Total Billed Charges,59.22,113.4,
KENALOG ORA 5GMD,5006272,CDM,270,RC,,,Outpatient,,,46.00,46.00,,27.03,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.03,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.27,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,41.4,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,41.4,90,,9.576,Percent of Total Billed Charges,90% of Total Billed Charges,21.62,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,41.4,90,,9.576,Percent of Total Billed Charges,90% of Total Billed Charges,27.03,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.62,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,21.62,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.62,47,,40.232,Percent of Total Billed Charges,47% of Total Billed Charges,21.62,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,21.62,41.4,
ZYLOPRIM 300MG TAB,5006273,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,9.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,9.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MEDROL DOSEPAK 4MG,5006274,CDM,259,RC,,,Outpatient,,,79.00,79.00,,46.41,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.41,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.24,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,71.1,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,71.1,90,,35.28,Percent of Total Billed Charges,90% of Total Billed Charges,37.13,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,71.1,90,,35.28,Percent of Total Billed Charges,90% of Total Billed Charges,46.41,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.13,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,37.13,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.13,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,37.13,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,37.13,71.1,
DURARESIC 25MG/HR PA,5007001,CDM,259,RC,,,Outpatient,,,95.00,95.00,,55.81,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,55.81,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.99,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,85.5,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,85.5,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,44.65,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,85.5,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,55.81,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,44.65,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,44.65,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,44.65,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,44.65,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,44.65,85.5,
DURAGESIC 50MG/HR PA,5007002,CDM,259,RC,,,Outpatient,,,158.00,158.00,,92.83,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,92.83,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.49,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,142.2,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,142.2,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,74.26,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,142.2,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,92.83,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,74.26,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,74.26,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,74.26,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,74.26,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,74.26,142.2,
AMARYL 4 MG TAB,5007003,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,96.824,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
CHLORDIAZEPOXIDE 25,5007007,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,96.824,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,5,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CHLORDIAZEPOXIDE 5MG,5007012,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
LEVOTHYROXIN 0.075MG,5007026,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,18.424,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
THERAGRAN HEMATINIC,5007032,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,18.424,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
GENTAMYCIN 60MGH,5007038,CDM,250,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
BETAPACE 80G,5007041,CDM,259,RC,,,Outpatient,,,12.00,12.00,,7.05,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
STRESSTAB 600 O,5007048,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
STRESSTABS 600 W/FE,5007049,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
STRESSTABS 600 W/ZN,5007050,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,118.08,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
OSCAL O,5007071,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,6.336,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
QUININE 325MG CAP,5007096,CDM,250,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DIGOXIN INJ,5007104,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,20.912,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,20.304,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,20.304,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,20.304,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
STERAPRED DS (12DAY),5007111,CDM,259,RC,,,Outpatient,,,132.00,132.00,,77.55,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,77.55,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,63.9,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,118.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,118.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,62.04,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,118.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,77.55,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,62.04,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,62.04,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,62.04,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,62.04,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,62.04,118.8,
ENSURE 8OZ L,5007116,CDM,270,RC,,,Outpatient,,,12.10,12.10,,7.11,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.11,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.86,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.89,90,,46.728,Percent of Total Billed Charges,90% of Total Billed Charges,10.89,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,5.69,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,10.89,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,7.11,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.69,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.69,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.69,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.69,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,5.69,10.89,
ENSURE PLUS 8OZ,5007120,CDM,259,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,118.08,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,118.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
PREMARIN 0.9MG O,5007123,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,66.24,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,6.336,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,6.336,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PREMARIN 2.5 O,5007126,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,53.448,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,51.888,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,51.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,51.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PREMARIN VAG CR,5007127,CDM,270,RC,,,Outpatient,,,121.00,121.00,,71.09,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,71.09,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.58,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,108.9,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,108.9,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,56.87,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,108.9,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,71.09,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,56.87,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,56.87,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,56.87,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,56.87,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,56.87,108.9,
PREMARIN 1.25MGTAB,5007133,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,182.88,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
OCEAN NASAL SPRAY,5007138,CDM,259,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,13.464,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,46.728,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,46.728,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,61.664,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
FEOSOL TABLET O,5007172,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,22.968,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,61.664,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,3.312,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
FEOSOL ELIX 30ML L,5007173,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,137.52,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,66.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,66.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.312,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
FEOSOL ELIX 5MLO,5007174,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
FERROUS SUL 325MG O,5007175,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
FIBERCON TAB,5007184,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,182.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,182.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,24.4,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
HALOPERIDOL .5MG O,5007192,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,13.464,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,13.464,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,24.4,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
HALOPEREDAL 1MGO,5007193,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,22.968,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,22.968,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,34.592,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
HALOPERIDAL 2MGO,5007194,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,137.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,137.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,34.592,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
FOLIC ACID 1MG O,5007196,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
GUAIFENESIN 400MG,5007207,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,14.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,14.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
FLOMAX 0.4MG,5007216,CDM,259,RC,,,Outpatient,,,10.00,10.00,,5.88,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.88,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.84,48.41,,37.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,9,90,,375.12,Percent of Total Billed Charges,90% of Total Billed Charges,9,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,47,,36.472,Percent of Total Billed Charges,47% of Total Billed Charges,9,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,5.88,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,36.472,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.7,47,,36.472,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,47,,7.032,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,9,
BIAXIN 500MG TAB,5007223,CDM,259,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.032,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,11.992,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
ISOCAL LIQ 8OZ,5007226,CDM,259,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,11.992,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,71.816,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
ISOCAL 12OZ L,5007227,CDM,259,RC,,,Outpatient,,,12.00,12.00,,7.05,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,3.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,3.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,71.816,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
SYNTHROID .025MG O,5007232,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,18.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,17.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
SYNTHROID 0.05MG O,5007233,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,20.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,19.552,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
SYNTHROID 0.15MG O,5007234,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,39.504,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,375.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,38.352,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,375.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,38.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,38.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SYNTHROID .1MG O,5007235,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,2.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,42.12,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,2.48,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,2.48,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,2.48,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
SYNTHROID .2MG O,5007236,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,23.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,5.616,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SYNTHROID 0.3MGO,5007237,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,23.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
LIPITOR 10MG,5007251,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,3.928,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
MAG CITRATE BOTTLE,5007261,CDM,259,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,56.88,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,195.896,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
PROVERA 10MG O,5007265,CDM,259,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,3.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,142.56,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,3.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,195.896,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
MEGACE 20MG TAB,5007267,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,341.28,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,42.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,42.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MEGACE 40 MG TAB,5007268,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,5.616,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,5.616,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,23.688,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
TARKA 1/180 TAB,5007273,CDM,259,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,31.32,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,23.688,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
MULTI VIT TAB,5007290,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,38.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,3.928,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,37.224,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,3.928,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,37.224,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,37.224,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
PLAVIX 75 MG TAB,5007296,CDM,259,RC,,,Outpatient,,,27.00,27.00,,15.86,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.86,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.07,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,24.3,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,24.3,90,,56.88,Percent of Total Billed Charges,90% of Total Billed Charges,12.69,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,24.3,90,,56.88,Percent of Total Billed Charges,90% of Total Billed Charges,15.86,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.69,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,24.3,
CHLORDIAZEPOXIDE 10M,5007315,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,15.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,142.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,142.56,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,15.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,22,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PREVACID 30MG,5007327,CDM,259,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,92.16,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,341.28,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,341.28,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,22,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,2.936,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
THIAMINE 100MG TAB,5007335,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,16.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,15.792,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.936,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
NIACIN 100MG,5007336,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,9.296,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,31.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,31.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,9.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.048,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
NIACIN 50MG,5007340,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.048,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ORUDIS 75MG PO,5007357,CDM,259,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,25.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,25.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,25.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,74.448,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
PEPCID 20MG,5007367,CDM,259,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,74.448,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,178.224,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
SYNTHROID 0.125MG TB,5007376,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,104.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,92.16,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,101.896,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,92.16,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,101.896,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,101.896,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,178.224,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
POT CHL ELIXIR 10% 20MEQ/15ML,5007387,CDM,259,RC,,,Outpatient,,,38.00,38.00,,22.33,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.33,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.4,48.41,,6.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,34.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,34.2,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,34.2,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,22.33,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,6.768,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.86,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,47,,16.36,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,34.2,
K-TAB 10MEQ O,5007391,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,37.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,16.36,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,23.688,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
GEVRABON LIQ 30ML L,5007398,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,64.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,64.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,64.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,23.688,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
K-DUR 10 MG TAB,5007399,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
OSCAL FORTE O,5007401,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,100.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,48.128,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
PROMOD (DOSE),5007402,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,70.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,68.808,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,68.808,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,68.808,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,48.128,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.504,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MICRO K 8MEG CAP,5007405,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.112,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.96,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.96,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.96,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.504,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
K-DUR 20 MEQ,5007411,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,23.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,37.44,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,37.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,22.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
PROZAC 20MG O,5007437,CDM,259,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,15.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,42.48,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,15.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
BENADRYL ELIX 4OZ,5007438,CDM,259,RC,,,Outpatient,,,25.00,25.00,,14.69,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.69,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.1,48.41,,23.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,22.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,14.69,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,22.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.75,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,22.5,
GLYNASE 3MG TAB,5007439,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,18.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,100.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,100.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,17.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
HEMOCYTE PLUS,5007441,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,23.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SOD CHL .45% 3ML I,5007449,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,11.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,11.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
SUSTACAL 8OZ L,5007458,CDM,259,RC,,,Outpatient,,,12.00,12.00,,7.05,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,60.8,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,1.584,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,59.032,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,59.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,59.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
SUSACAL LIQ 12OZ L,5007459,CDM,259,RC,,,Outpatient,,,12.00,12.00,,7.05,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,42.48,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,42.48,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
SUSTACAL PUDDING 5OZ,5007462,CDM,259,RC,,,Outpatient,,,12.00,12.00,,7.05,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,52.264,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
THYROID 120MG 2GR,5007480,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,45.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,45.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,13.944,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,45.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,13.536,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,52.264,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
THYROID 15MG 1/4GR,5007481,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,48.24,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
THYROID 30MG 1/2GR,5007485,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
THYROID 60MG 1GR,5007486,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,48.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,1.584,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,47.152,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,1.584,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,47.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,47.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,22.184,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
"VITAMIN D 50,000 U O",5007520,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,6.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.768,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,22.184,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
VITAMIN E 100 IU O,5007523,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,24.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,24.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,12.008,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,11.656,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,24.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,11.656,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,11.656,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
VITAMIN E 200IUO,5007525,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,47.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,47.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,15.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,47.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,15.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
VITAMIN E 400 IU O,5007527,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,3.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,3.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,48.24,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,48.24,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,3.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
ZESTORETIC,5007538,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,9.296,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,9.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,0.824,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
ZITHROMAX 250MGCAP,5007551,CDM,259,RC,,,Outpatient,,,54.00,54.00,,31.73,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.73,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,26.14,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,48.6,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,48.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,25.38,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,48.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,31.73,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,25.38,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,25.38,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,25.38,47,,0.824,Percent of Total Billed Charges,47% of Total Billed Charges,25.38,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,25.38,48.6,
MICRONASE 2.5MGPO,5007553,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,26.928,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MICRONASE 5MG PO,5007554,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,10.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,10.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CHROMAGEN CAP O,5007555,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,25.192,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MICRO-K 10 MEQ CAP,5007557,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,15.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,15.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,25.192,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
CEREBYX 100MG INJ,5007562,CDM,250,RC,,,Outpatient,,,138.00,138.00,,81.08,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,81.08,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.81,48.41,,23.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,124.2,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,124.2,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,64.86,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,124.2,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,81.08,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,64.86,47,,22.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,64.86,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,64.86,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,64.86,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,64.86,124.2,
GLUCATROL 10MG,5007579,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,23.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
GLUCOTROL 5MG,5007580,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,46.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,46.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,8.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,26.928,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,26.928,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,46.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,8.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
COUMADIN 10MG O,5008030,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,23.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
COUMADIN 2.5MG O,5008031,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,8.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,44.64,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,8.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
COUMADIN 2MG O,5008032,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,23.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
COUMADIN 5MG O,5008033,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,19.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,19.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,50.4,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,19.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
COUMADIN 7.5MG O,5008034,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,14.064,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
NORMODYNE 200MG,5008246,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,14.064,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
NORMODYNE 300MGPO,5008247,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,12.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,12.408,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TOPROL XL 50MG,5008279,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,44.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,44.64,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
DIAMOX 125MG TAB O,5009011,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,127.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,127.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,127.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DIAMOX 250MG O,5009012,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,50.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,50.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DIFLUCAN 100MG,5009013,CDM,259,RC,,,Outpatient,,,38.00,38.00,,22.33,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.33,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.4,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,34.2,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,34.2,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,34.2,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,22.33,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.86,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,34.2,
VOSOL 15ML OTICOS,5009023,CDM,259,RC,,,Outpatient,,,97.00,97.00,,56.99,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,56.99,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.96,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,87.3,90,,87.12,Percent of Total Billed Charges,90% of Total Billed Charges,87.3,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,45.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,87.3,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,56.99,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,45.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.59,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,45.59,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,45.59,87.3,
ALBUTEROL SOLN 1/2ML,5009029,CDM,250,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,28.512,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,23.312,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
HALOPERIDAL 5MGO,5009035,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,23.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,41.184,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,23.312,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ALTACE 5MG,5009045,CDM,259,RC,,,Outpatient,,,9.00,9.00,,5.29,58.75,,86.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.29,58.75,,86.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.36,48.41,,45.312,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.1,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,47,,43.992,Percent of Total Billed Charges,47% of Total Billed Charges,8.1,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,58.75,,86.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,43.992,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.23,47,,43.992,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,47,,26.32,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,8.1,
AUGMENTIN 125 75ML,5009085,CDM,259,RC,,,Outpatient,,,47.00,47.00,,27.61,58.75,,6.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.61,58.75,,6.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.75,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.3,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,42.3,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,22.09,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,42.3,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,27.61,58.75,,6.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,22.09,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,26.32,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,42.3,
ATROPINE 1MG CARDIAC,5009086,CDM,250,RC,,,Outpatient,,,52.00,52.00,,30.55,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.55,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.17,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,46.8,90,,26.928,Percent of Total Billed Charges,90% of Total Billed Charges,46.8,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,24.44,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,46.8,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,30.55,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.44,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,24.44,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.44,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,24.44,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,24.44,46.8,
ATROPINE OS 1%,5009087,CDM,259,RC,,,Outpatient,,,102.00,102.00,,59.93,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,59.93,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.38,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,91.8,90,,49.104,Percent of Total Billed Charges,90% of Total Billed Charges,91.8,90,,87.12,Percent of Total Billed Charges,90% of Total Billed Charges,47.94,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,91.8,90,,87.12,Percent of Total Billed Charges,90% of Total Billed Charges,59.93,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47.94,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47.94,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47.94,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,47.94,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,47.94,91.8,
ATIVAN .5 MG TAB,5009089,CDM,259,RC,,,Outpatient,,,6.60,6.60,,3.88,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.88,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.2,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.94,90,,45.144,Percent of Total Billed Charges,90% of Total Billed Charges,5.94,90,,28.512,Percent of Total Billed Charges,90% of Total Billed Charges,3.1,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,5.94,90,,28.512,Percent of Total Billed Charges,90% of Total Billed Charges,3.88,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.1,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.1,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.1,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,3.1,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,3.1,5.94,
ISOPTO ATROP .50%5ML,5009093,CDM,259,RC,,,Outpatient,,,61.00,61.00,,35.84,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.84,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.53,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,54.9,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,90,,41.184,Percent of Total Billed Charges,90% of Total Billed Charges,28.67,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,54.9,90,,41.184,Percent of Total Billed Charges,90% of Total Billed Charges,35.84,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.67,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,54.9,
ISOPTO CARP 0.25% 15,5009102,CDM,259,RC,,,Outpatient,,,61.00,61.00,,35.84,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.84,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.53,48.41,,24.28,Percent of Total Billed Charges,48.41% of Total Billed Charges,54.9,90,,44.64,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,28.67,47,,23.576,Percent of Total Billed Charges,47% of Total Billed Charges,54.9,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,35.84,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,23.576,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.67,47,,23.576,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,54.9,
BUMEX 2MG INJ,5009161,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,4.688,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,100.08,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,4.552,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,4.552,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,4.552,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
TEGRETOL O,5009185,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,73.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,73.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,6.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,79.92,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,26.928,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,26.928,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,73.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.768,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,45.496,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CARDIZEM CD 180MG,5009189,CDM,259,RC,,,Outpatient,,,9.00,9.00,,5.29,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.29,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.36,48.41,,19.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.1,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,90,,49.104,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,8.1,90,,49.104,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,19.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.23,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,45.496,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,47,,14.888,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,8.1,
PROCARDIA 20MG,5009191,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,6.336,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,45.144,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,45.144,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,14.888,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,21.504,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
AURALGAN EAR G,5009208,CDM,259,RC,,,Outpatient,,,32.00,32.00,,18.8,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,8.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.8,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,15.04,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,28.8,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,8.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,21.504,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,47,,28.952,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,28.8,
CHLOR TRI 4MG O,5009214,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,10.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,44.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,44.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,9.776,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,28.952,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CEFZIL 125MG/5ML(50),5009220,CDM,259,RC,,,Outpatient,,,99.00,99.00,,58.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.93,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,89.1,90,,8.32,Percent of Total Billed Charges,90% of Total Billed Charges,89.1,90,,100.08,Percent of Total Billed Charges,90% of Total Billed Charges,46.53,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,89.1,90,,100.08,Percent of Total Billed Charges,90% of Total Billed Charges,58.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.53,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,46.53,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.53,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,46.53,47,,14.064,Percent of Total Billed Charges,47% of Total Billed Charges,46.53,89.1,
ZYLOPRIM 100MG TAB,5009221,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,58.936,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,58.936,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,13.944,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,79.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,79.92,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,58.936,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,13.536,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,14.064,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,25.64,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PROCHLORPERAZINE 10H,5009275,CDM,250,RC,,,Outpatient,,,40.00,40.00,,23.5,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.5,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.36,48.41,,14.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,36,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,36,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,36,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,23.5,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,14.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.8,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,25.64,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,47,,23.576,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,36,
CYPROHEPTADINE 4 MG,5009290,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,14.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,14.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,24.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,39.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,6.336,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,6.336,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,14.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,24.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,23.576,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DACRIOSE 4OZ OS,5009293,CDM,259,RC,,,Outpatient,,,42.00,42.00,,24.68,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.68,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.33,48.41,,3.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,37.8,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,37.8,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,19.74,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,37.8,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,24.68,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.74,47,,3.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,19.74,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.74,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,19.74,47,,23.312,Percent of Total Billed Charges,47% of Total Billed Charges,19.74,37.8,
DACRIOSE 30ML OS,5009295,CDM,250,RC,,,Outpatient,,,24.00,24.00,,14.1,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.1,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.62,48.41,,424.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.6,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,21.6,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,11.28,47,,411.72,Percent of Total Billed Charges,47% of Total Billed Charges,21.6,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,411.72,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.28,47,,411.72,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,23.312,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,47,,52.264,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,21.6,
DEPAKOTE 250MG O,5009298,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,8.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,8.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,52.264,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,41.736,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
DESITIN OINT 1.25OZ,5009299,CDM,270,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,5.296,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,41.736,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
GLYBURIDE 5MG,5009304,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,9.296,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,9.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,3.312,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
GASTROGRAFIN 120ML,5009309,CDM,250,RC,,,Outpatient,,,271.00,271.00,,159.21,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,159.21,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,131.19,48.41,,10.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,243.9,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,243.9,90,,39.6,Percent of Total Billed Charges,90% of Total Billed Charges,127.37,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,243.9,90,,39.6,Percent of Total Billed Charges,90% of Total Billed Charges,159.21,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,127.37,47,,10.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,127.37,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,127.37,47,,3.312,Percent of Total Billed Charges,47% of Total Billed Charges,127.37,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,127.37,243.9,
ZOLOFT TAB,5009324,CDM,259,RC,,,Outpatient,,,18.00,18.00,,10.58,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.58,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.71,48.41,,8.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.2,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,8.46,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,16.2,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,10.58,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,7.896,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.46,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,16.2,
BENADRYL 25MG O,5009327,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,19.368,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,6.552,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,18.8,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,18.8,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,18.8,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,4.344,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
BENADRYL ELIX DOSE,5009328,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,9.296,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,9.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,4.344,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
BENADRYL 50MG O,5009329,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,71.104,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,5.296,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,5.296,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
RACEPINEPHRINE SOL,5009348,CDM,250,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,54.4,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,20.68,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
ELASE OINT 30GMD,5009373,CDM,270,RC,,,Outpatient,,,183.00,183.00,,107.51,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,107.51,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,88.59,48.41,,10.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,164.7,90,,4.104,Percent of Total Billed Charges,90% of Total Billed Charges,164.7,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,86.01,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,164.7,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,107.51,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,86.01,47,,10.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,86.01,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,86.01,47,,20.68,Percent of Total Billed Charges,47% of Total Billed Charges,86.01,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,86.01,164.7,
FLUOR-I-STRIP OPTH D,5009378,CDM,250,RC,,,Outpatient,,,13.20,13.20,,7.76,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.76,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.39,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.88,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,11.88,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,6.2,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,11.88,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,7.76,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.2,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.2,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.2,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,6.2,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,6.2,11.88,
ISOPTO HOMATRO 2%15,5009402,CDM,259,RC,,,Outpatient,,,61.00,61.00,,35.84,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.84,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.53,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,54.9,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,90,,6.552,Percent of Total Billed Charges,90% of Total Billed Charges,28.67,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,54.9,90,,6.552,Percent of Total Billed Charges,90% of Total Billed Charges,35.84,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.67,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,54.9,
HOMATROPINE 2% 5ML,5009404,CDM,259,RC,,,Outpatient,,,40.00,40.00,,23.5,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.5,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.36,48.41,,23.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,36,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,36,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,36,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,23.5,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,22.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.8,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,47,,2.76,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,36,
ISOPTO HOMATRO 5%15,5009405,CDM,259,RC,,,Outpatient,,,61.00,61.00,,35.84,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.84,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.53,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,54.9,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,90,,71.104,Percent of Total Billed Charges,90% of Total Billed Charges,28.67,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,54.9,90,,71.104,Percent of Total Billed Charges,90% of Total Billed Charges,35.84,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.67,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,2.76,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,54.9,
HOMATROPINE 5% 5ML,5009408,CDM,259,RC,,,Outpatient,,,47.00,47.00,,27.61,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.61,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.75,48.41,,11.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.3,90,,6.624,Percent of Total Billed Charges,90% of Total Billed Charges,42.3,90,,54.4,Percent of Total Billed Charges,90% of Total Billed Charges,22.09,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,42.3,90,,54.4,Percent of Total Billed Charges,90% of Total Billed Charges,27.61,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,11.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,22.09,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,42.3,
ISOPTO TEARS 15ML OS,5009422,CDM,259,RC,,,Outpatient,,,61.00,61.00,,35.84,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.84,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.53,48.41,,8.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,54.9,90,,8.568,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,90,,4.104,Percent of Total Billed Charges,90% of Total Billed Charges,28.67,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,54.9,90,,4.104,Percent of Total Billed Charges,90% of Total Billed Charges,35.84,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,7.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.67,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,54.9,
KERI LOT 195ML,5009444,CDM,259,RC,,,Outpatient,,,30.00,30.00,,17.63,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.63,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.52,48.41,,8.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,27,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,27,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,27,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,17.63,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,7.896,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.1,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,47,,3.424,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,27,
ZITHROMAX 500MGINJ,5009447,CDM,250,RC,,,Outpatient,,,157.00,157.00,,92.24,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,92.24,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,76,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,141.3,90,,10.744,Percent of Total Billed Charges,90% of Total Billed Charges,141.3,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,73.79,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,141.3,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,92.24,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,73.79,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,73.79,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,73.79,47,,3.424,Percent of Total Billed Charges,47% of Total Billed Charges,73.79,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,73.79,141.3,
LANOXIN 0.25MG TAB,5009462,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,8.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,37.128,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
PRILOSEC 20MG,5009465,CDM,259,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,133.848,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,37.128,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,28.408,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
LIQUIFILM FORTE15ML,5009466,CDM,259,RC,,,Outpatient,,,36.00,36.00,,21.15,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.15,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.43,48.41,,3.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,32.4,90,,4.648,Percent of Total Billed Charges,90% of Total Billed Charges,32.4,90,,6.624,Percent of Total Billed Charges,90% of Total Billed Charges,16.92,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,32.4,90,,6.624,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.92,47,,3.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.92,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.92,47,,28.408,Percent of Total Billed Charges,47% of Total Billed Charges,16.92,47,,2.144,Percent of Total Billed Charges,47% of Total Billed Charges,16.92,32.4,
URISPAS 100MG,5009507,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,2.848,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,8.568,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,8.568,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
VASOTEC 2.5MG PO,5009514,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ULTRAVIST 50ML,5009536,CDM,255,RC,,,Outpatient,,,125.40,125.40,,73.67,58.75,,54.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.67,58.75,,54.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,60.71,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,112.86,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,112.86,90,,10.744,Percent of Total Billed Charges,90% of Total Billed Charges,58.94,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,112.86,90,,10.744,Percent of Total Billed Charges,90% of Total Billed Charges,73.67,58.75,,54.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,58.94,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,58.94,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,58.94,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,58.94,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,58.94,112.86,
ORABASE ORAL 5GM,5009544,CDM,259,RC,,,Outpatient,,,18.00,18.00,,10.58,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.58,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.71,48.41,,9.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.2,90,,87.696,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,8.46,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,16.2,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,10.58,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,9.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.46,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,16.2,
VANTIN 200MG,5009555,CDM,259,RC,,,Outpatient,,,31.00,31.00,,18.21,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.21,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.01,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,27.9,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,27.9,90,,133.848,Percent of Total Billed Charges,90% of Total Billed Charges,14.57,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,27.9,90,,133.848,Percent of Total Billed Charges,90% of Total Billed Charges,18.21,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.57,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.57,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.57,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,14.57,47,,3.456,Percent of Total Billed Charges,47% of Total Billed Charges,14.57,27.9,
LACRI-LUBE OINTOO,5009561,CDM,270,RC,,,Outpatient,,,40.00,40.00,,23.5,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.5,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.36,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,36,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,36,90,,4.648,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,36,90,,4.648,Percent of Total Billed Charges,90% of Total Billed Charges,23.5,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.8,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,3.456,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,47,,4.472,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,36,
CHLORASEPTIC LOZ,5009574,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,2.848,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,2.848,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.472,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CHLORASEPTIC SPR 6OZ,5009576,CDM,259,RC,,,Outpatient,,,24.00,24.00,,14.1,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.1,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.62,48.41,,41.248,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.6,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,21.6,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,11.28,47,,40.048,Percent of Total Billed Charges,47% of Total Billed Charges,21.6,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,40.048,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.28,47,,40.048,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,47,,5.608,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,21.6,
CHLORASEPTIC 1.5OZ,5009577,CDM,259,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,29.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,29.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,15.76,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,15.304,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,29.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,15.304,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,15.304,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,5.608,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
NEO-SYNEPH NAS .25%,5009584,CDM,259,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,5.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,5.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,19.872,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,87.696,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,87.696,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,5.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,69.896,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
NEOSYNEPH GTT 15ML,5009586,CDM,259,RC,,,Outpatient,,,27.00,27.00,,15.86,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.86,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.07,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,24.3,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,24.3,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,12.69,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,24.3,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,15.86,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.69,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,69.896,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,47,,2.432,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,24.3,
NEO-SYNEPH .5% 1OZ,5009588,CDM,259,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,8.464,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,2.432,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,1.488,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
NEO-SYNEPH 10% 5ML,5009592,CDM,259,RC,,,Outpatient,,,40.00,40.00,,23.5,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.5,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.36,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,36,90,,7.456,Percent of Total Billed Charges,90% of Total Billed Charges,36,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,36,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,23.5,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.8,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,1.488,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,36,
ISOPTO CARP 0.5% 15M,5009612,CDM,259,RC,,,Outpatient,,,61.00,61.00,,35.84,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.84,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.53,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,54.9,90,,22.36,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,28.67,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,54.9,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,35.84,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.67,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,54.9,
ISOPTO CARP 1% 15ML,5009613,CDM,259,RC,,,Outpatient,,,61.00,61.00,,35.84,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.84,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.53,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,54.9,90,,14.04,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,28.67,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,54.9,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,35.84,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.67,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,47,,45.8,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,54.9,
PILOCARPINE 1% 2ML,5009615,CDM,259,RC,,,Outpatient,,,23.00,23.00,,13.51,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.51,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.13,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.7,90,,10.944,Percent of Total Billed Charges,90% of Total Billed Charges,20.7,90,,19.872,Percent of Total Billed Charges,90% of Total Billed Charges,10.81,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,20.7,90,,19.872,Percent of Total Billed Charges,90% of Total Billed Charges,13.51,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.81,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,45.8,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,20.7,
ISOPTO CARP 2% 15ML,5009618,CDM,259,RC,,,Outpatient,,,61.00,61.00,,35.84,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.84,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.53,48.41,,84.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,54.9,90,,10.008,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,28.67,47,,81.968,Percent of Total Billed Charges,47% of Total Billed Charges,54.9,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,35.84,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,81.968,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.67,47,,81.968,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,54.9,
PILOCARPINE 2% 2ML,5009620,CDM,259,RC,,,Outpatient,,,23.00,23.00,,13.51,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.51,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.13,48.41,,46.088,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.7,90,,15.448,Percent of Total Billed Charges,90% of Total Billed Charges,20.7,90,,8.464,Percent of Total Billed Charges,90% of Total Billed Charges,10.81,47,,44.744,Percent of Total Billed Charges,47% of Total Billed Charges,20.7,90,,8.464,Percent of Total Billed Charges,90% of Total Billed Charges,13.51,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,44.744,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.81,47,,44.744,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,20.7,
ISOPTO CARP 4% 15ML,5009622,CDM,259,RC,,,Outpatient,,,61.00,61.00,,35.84,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.84,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.53,48.41,,11.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,54.9,90,,25.384,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,90,,7.456,Percent of Total Billed Charges,90% of Total Billed Charges,28.67,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,54.9,90,,7.456,Percent of Total Billed Charges,90% of Total Billed Charges,35.84,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,11.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.67,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,54.9,
PHENERGAN 12.5MG,5009664,CDM,259,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,15.48,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,22.36,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,22.36,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
PHENERGAN 25MG TAB,5009665,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,514.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,514.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,108.824,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,79.632,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,14.04,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,105.656,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,14.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,514.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,105.656,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,105.656,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,10.376,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
PHENERGAN 50MG,5009666,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,12.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,9.504,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,10.944,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,10.944,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,12.408,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,10.376,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MOTRIN LIQ BOTTLE,5009676,CDM,259,RC,,,Outpatient,,,33.00,33.00,,19.39,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.39,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.98,48.41,,42.216,Percent of Total Billed Charges,48.41% of Total Billed Charges,29.7,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,29.7,90,,10.008,Percent of Total Billed Charges,90% of Total Billed Charges,15.51,47,,40.984,Percent of Total Billed Charges,47% of Total Billed Charges,29.7,90,,10.008,Percent of Total Billed Charges,90% of Total Billed Charges,19.39,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,40.984,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.51,47,,40.984,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,47,,4.416,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,29.7,
PYRIDOXIME 50 MG B-6,5009683,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,32.144,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,15.448,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,31.208,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,15.448,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,31.208,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,31.208,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.416,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,3.888,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SELSUN 120ML D,5009713,CDM,259,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,14.8,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,25.384,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,25.384,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,3.888,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,11.672,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
SILVER NITRATE APP,5009720,CDM,270,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,6.376,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,15.48,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,15.48,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,11.672,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,7.336,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
NORMAL SALINE NASAL,5009740,CDM,259,RC,,,Outpatient,,,12.00,12.00,,7.05,58.75,,23.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,23.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,14.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,3.488,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,79.632,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,79.632,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,23.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,13.912,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,7.336,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,5.712,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
PHENERG VC/COD DOSE,5009742,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,20.912,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,9.504,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,20.304,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,9.504,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,20.304,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,20.304,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.712,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,5.224,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SORBITOL LIQ 30ML L,5009752,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,34.08,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,33.088,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,33.088,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,33.088,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.224,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,8.064,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TEDS KNEE HIGH PR,5009795,CDM,270,RC,,,Outpatient,,,61.00,61.00,,35.84,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.84,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.53,48.41,,68.16,Percent of Total Billed Charges,48.41% of Total Billed Charges,54.9,90,,675,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,28.67,47,,66.176,Percent of Total Billed Charges,47% of Total Billed Charges,54.9,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,35.84,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,66.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.67,47,,66.176,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,8.064,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,47,,13.256,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,54.9,
TEDS THIGH HIGHPR,5009796,CDM,270,RC,,,Outpatient,,,117.00,117.00,,68.74,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,68.74,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,56.64,48.41,,9.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,105.3,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,105.3,90,,14.8,Percent of Total Billed Charges,90% of Total Billed Charges,54.99,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,105.3,90,,14.8,Percent of Total Billed Charges,90% of Total Billed Charges,68.74,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,54.99,47,,9.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,54.99,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,54.99,47,,13.256,Percent of Total Billed Charges,47% of Total Billed Charges,54.99,47,,8.088,Percent of Total Billed Charges,47% of Total Billed Charges,54.99,105.3,
TENEX,5009820,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,747.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,482.728,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,6.376,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,726.056,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,6.376,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,726.056,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,726.056,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,8.088,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,41.584,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ATENOLOL 25MG TAB,5009821,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,259.992,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,3.488,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,3.488,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,41.584,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,4.96,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
PAXIL 10MG,5009825,CDM,259,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,1605.496,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,4.96,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
PEDIALYTE 6 OZ,5009831,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,14.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,7.688,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,14.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
GLUCOPHAGE 500 MG,5009838,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,675,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,675,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,7.728,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
"GO LYTELY, GAL",5009839,CDM,250,RC,,,Outpatient,,,62.70,62.70,,36.84,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.84,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.35,48.41,,8.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,56.43,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,56.43,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,29.47,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,56.43,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,36.84,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.47,47,,7.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,29.47,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.47,47,,7.728,Percent of Total Billed Charges,47% of Total Billed Charges,29.47,47,,3.328,Percent of Total Billed Charges,47% of Total Billed Charges,29.47,56.43,
CIPRO 250MG,5009840,CDM,259,RC,,,Outpatient,,,12.10,12.10,,7.11,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.11,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.86,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.89,90,,79.216,Percent of Total Billed Charges,90% of Total Billed Charges,10.89,90,,482.728,Percent of Total Billed Charges,90% of Total Billed Charges,5.69,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,10.89,90,,482.728,Percent of Total Billed Charges,90% of Total Billed Charges,7.11,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.69,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.69,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.69,47,,3.328,Percent of Total Billed Charges,47% of Total Billed Charges,5.69,47,,1.816,Percent of Total Billed Charges,47% of Total Billed Charges,5.69,10.89,
CIPRO 500MG,5009841,CDM,259,RC,,,Outpatient,,,18.00,18.00,,10.58,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.58,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.71,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.2,90,,84.24,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,90,,259.992,Percent of Total Billed Charges,90% of Total Billed Charges,8.46,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,16.2,90,,259.992,Percent of Total Billed Charges,90% of Total Billed Charges,10.58,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.46,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,1.816,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,16.2,
PHENERG VC/COD 4 OZ,5009850,CDM,259,RC,,,Outpatient,,,51.00,51.00,,29.96,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.96,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.69,48.41,,23.24,Percent of Total Billed Charges,48.41% of Total Billed Charges,45.9,90,,5.112,Percent of Total Billed Charges,90% of Total Billed Charges,45.9,90,,1605.496,Percent of Total Billed Charges,90% of Total Billed Charges,23.97,47,,22.56,Percent of Total Billed Charges,47% of Total Billed Charges,45.9,90,,1605.496,Percent of Total Billed Charges,90% of Total Billed Charges,29.96,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,22.56,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.97,47,,22.56,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,45.9,
LORTAB 5,5009853,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,23.24,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,5.112,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,7.688,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,22.56,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,7.688,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,22.56,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,22.56,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,352.504,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
ZINC OXIDE 30GM,5009882,CDM,270,RC,,,Outpatient,,,23.00,23.00,,13.51,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.51,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.13,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.7,90,,19.912,Percent of Total Billed Charges,90% of Total Billed Charges,20.7,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,10.81,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,20.7,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,13.51,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.81,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,80.688,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,47,,277.304,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,20.7,
FUROSEMIDE 40MGH,5009923,CDM,250,RC,,,Outpatient,,,26.00,26.00,,15.28,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.28,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.59,48.41,,10.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,23.4,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,23.4,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,12.22,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,23.4,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,15.28,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.22,47,,9.776,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.22,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.22,47,,110.504,Percent of Total Billed Charges,47% of Total Billed Charges,12.22,47,,252.088,Percent of Total Billed Charges,47% of Total Billed Charges,12.22,23.4,
NICORETTE GUM 2MG,5009945,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,8.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,20.232,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,79.216,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,79.216,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,81.616,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,135.776,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
STADOL 1MG/1ML H,5010003,CDM,250,RC,,,Outpatient,,,36.00,36.00,,21.15,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.15,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.43,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,32.4,90,,43.96,Percent of Total Billed Charges,90% of Total Billed Charges,32.4,90,,84.24,Percent of Total Billed Charges,90% of Total Billed Charges,16.92,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,32.4,90,,84.24,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.92,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.92,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.92,47,,61.848,Percent of Total Billed Charges,47% of Total Billed Charges,16.92,47,,838.424,Percent of Total Billed Charges,47% of Total Billed Charges,16.92,32.4,
STADOL 2MG/ML 1ML H,5010004,CDM,250,RC,,,Outpatient,,,38.00,38.00,,22.33,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.33,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.4,48.41,,19.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,34.2,90,,5.112,Percent of Total Billed Charges,90% of Total Billed Charges,34.2,90,,5.112,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,34.2,90,,5.112,Percent of Total Billed Charges,90% of Total Billed Charges,22.33,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,19.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.86,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,61.848,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,47,,4.016,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,34.2,
STADOL 4MG/2ML H,5010005,CDM,250,RC,,,Outpatient,,,64.00,64.00,,37.6,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.6,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.98,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,57.6,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,57.6,90,,5.112,Percent of Total Billed Charges,90% of Total Billed Charges,30.08,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,57.6,90,,5.112,Percent of Total Billed Charges,90% of Total Billed Charges,37.6,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.08,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,30.08,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.08,47,,81.616,Percent of Total Billed Charges,47% of Total Billed Charges,30.08,47,,336.52,Percent of Total Billed Charges,47% of Total Billed Charges,30.08,57.6,
NEURONTIN 300MGCAP,5010009,CDM,259,RC,,,Outpatient,,,10.00,10.00,,5.88,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.88,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.84,48.41,,29.824,Percent of Total Billed Charges,48.41% of Total Billed Charges,9,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,9,90,,19.912,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,47,,28.952,Percent of Total Billed Charges,47% of Total Billed Charges,9,90,,19.912,Percent of Total Billed Charges,90% of Total Billed Charges,5.88,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,28.952,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.7,47,,28.952,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,91.928,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,47,,6.408,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,9,
NEUPOGEN ING 300MG,5010010,CDM,250,RC,,,Outpatient,,,1095.00,1095.00,,643.31,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,643.31,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,530.09,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,985.5,90,,5.4,Percent of Total Billed Charges,90% of Total Billed Charges,985.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,514.65,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,985.5,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,643.31,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,514.65,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,514.65,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,514.65,47,,88.144,Percent of Total Billed Charges,47% of Total Billed Charges,514.65,47,,12.52,Percent of Total Billed Charges,47% of Total Billed Charges,514.65,985.5,
SUBLIMAZE 2ML H,5010027,CDM,250,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,50.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,50.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,8.824,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,20.232,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,20.232,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,50.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,21.696,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
SUBLIMAZE 5ML H,5010028,CDM,250,RC,,,Outpatient,,,32.00,32.00,,18.8,58.75,,19.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,19.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.8,90,,26.28,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,90,,43.96,Percent of Total Billed Charges,90% of Total Billed Charges,15.04,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,28.8,90,,43.96,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,58.75,,19.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,21.696,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,28.8,
XYLOCAINE .5% 50CC,5010050,CDM,250,RC,,,Outpatient,,,24.00,24.00,,14.1,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.1,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.62,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.6,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,21.6,90,,5.112,Percent of Total Billed Charges,90% of Total Billed Charges,11.28,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,21.6,90,,5.112,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.28,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,21.696,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,47,,4.776,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,21.6,
XYLOCAINE 1% PER ML,5010052,CDM,250,RC,,,Outpatient,,,27.00,27.00,,15.86,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.86,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.07,48.41,,58.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,24.3,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,24.3,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,12.69,47,,56.4,Percent of Total Billed Charges,47% of Total Billed Charges,24.3,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,15.86,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,56.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.69,47,,56.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,21.696,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,47,,14.76,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,24.3,
XYLOCAINE 1% 2ML H,5010053,CDM,250,RC,,,Outpatient,,,21.00,21.00,,12.34,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.34,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.17,48.41,,36.016,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.9,90,,3591.52,Percent of Total Billed Charges,90% of Total Billed Charges,18.9,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,47,,34.968,Percent of Total Billed Charges,47% of Total Billed Charges,18.9,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,12.34,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.87,47,,34.968,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.87,47,,34.968,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.87,47,,352.504,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,18.9,
XYLOCAIN 1% 30ML H,5010054,CDM,250,RC,,,Outpatient,,,50.00,50.00,,29.38,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.38,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.21,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,45,90,,3591.52,Percent of Total Billed Charges,90% of Total Billed Charges,45,90,,5.4,Percent of Total Billed Charges,90% of Total Billed Charges,23.5,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,45,90,,5.4,Percent of Total Billed Charges,90% of Total Billed Charges,29.38,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.5,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.5,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.5,47,,277.304,Percent of Total Billed Charges,47% of Total Billed Charges,23.5,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,23.5,45,
XYLOCAINE 2% PER ML,5010059,CDM,250,RC,,,Outpatient,,,24.00,24.00,,14.1,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.1,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.62,48.41,,14.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.6,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,21.6,90,,8.824,Percent of Total Billed Charges,90% of Total Billed Charges,11.28,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,21.6,90,,8.824,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,14.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.28,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,252.088,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,47,,10.432,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,21.6,
LIDOCAINE 2% INJ IM,5010070,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,37.176,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,26.28,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,26.28,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,36.096,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,135.776,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
LIDOCAINE INJ ANY,5010079,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,838.424,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
XYLOCAINE .5% EPI,5010081,CDM,250,RC,,,Outpatient,,,27.00,27.00,,15.86,58.75,,102.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.86,58.75,,102.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.07,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,24.3,90,,282.152,Percent of Total Billed Charges,90% of Total Billed Charges,24.3,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,12.69,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,24.3,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,15.86,58.75,,102.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.69,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,4.016,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,47,,1.52,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,24.3,
XYLOCAINE EPI 1% 20M,5010083,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,55.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,55.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,490.32,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,3591.52,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,3591.52,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,55.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,336.52,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
XYLOCAINE EPI 1% PER ML,5010085,CDM,250,RC,,,Outpatient,,,28.00,28.00,,16.45,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,9.8,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.2,90,,1004.4,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,90,,3591.52,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,47,,9.512,Percent of Total Billed Charges,47% of Total Billed Charges,25.2,90,,3591.52,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,9.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,9.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,6.408,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,25.2,
XYLOCAIN-EPI 1.5%,5010086,CDM,250,RC,,,Outpatient,,,61.00,61.00,,35.84,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.84,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.53,48.41,,26.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,54.9,90,,69.952,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,28.67,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,54.9,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,35.84,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,25.944,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.67,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,12.52,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,54.9,
XYLOCAINE EPI 2% 20M,5010088,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,132.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,132.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,881.64,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,132.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,5.096,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
XYLOCAINE EPI 2% PER ML,5010091,CDM,250,RC,,,Outpatient,,,30.00,30.00,,17.63,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.63,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.52,48.41,,15.008,Percent of Total Billed Charges,48.41% of Total Billed Charges,27,90,,277.208,Percent of Total Billed Charges,90% of Total Billed Charges,27,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,47,,14.568,Percent of Total Billed Charges,47% of Total Billed Charges,27,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,17.63,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,14.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.1,47,,14.568,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,47,,3.456,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,27,
DEMEROL 100MG H,5010094,CDM,250,RC,,,Outpatient,,,20.90,20.90,,12.28,58.75,,51.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.28,58.75,,51.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.12,48.41,,18.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.81,90,,1425.6,Percent of Total Billed Charges,90% of Total Billed Charges,18.81,90,,282.152,Percent of Total Billed Charges,90% of Total Billed Charges,9.82,47,,17.864,Percent of Total Billed Charges,47% of Total Billed Charges,18.81,90,,282.152,Percent of Total Billed Charges,90% of Total Billed Charges,12.28,58.75,,51.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,17.864,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.82,47,,17.864,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,4.776,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,47,,14.76,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,18.81,
DEMEROL 25MG INJ H,5010096,CDM,250,RC,,,Outpatient,,,21.00,21.00,,12.34,58.75,,39.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.34,58.75,,39.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.17,48.41,,34.08,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.9,90,,1613.52,Percent of Total Billed Charges,90% of Total Billed Charges,18.9,90,,490.32,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,47,,33.088,Percent of Total Billed Charges,47% of Total Billed Charges,18.9,90,,490.32,Percent of Total Billed Charges,90% of Total Billed Charges,12.34,58.75,,39.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.87,47,,33.088,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.87,47,,33.088,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.87,47,,14.76,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,18.9,
MEPERIDINE 25MG,5010097,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,53.448,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,427.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,1004.4,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,51.888,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,1004.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,51.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,51.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
DEMEROL 50MG H,5010098,CDM,250,RC,,,Outpatient,,,20.90,20.90,,12.28,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.28,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.12,48.41,,14.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,18.81,90,,69.952,Percent of Total Billed Charges,90% of Total Billed Charges,9.82,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,18.81,90,,69.952,Percent of Total Billed Charges,90% of Total Billed Charges,12.28,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,14.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.82,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,47,,12.48,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,18.81,
DEMEROL 75MG H,5010100,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,19.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,881.64,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,881.64,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,19.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,10.432,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,88.08,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
CARDIZEM CD 120MG,5010104,CDM,259,RC,,,Outpatient,,,9.00,9.00,,5.29,58.75,,25.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.29,58.75,,25.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.36,48.41,,24.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.1,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,90,,277.208,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,8.1,90,,277.208,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,58.75,,25.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,24.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.23,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,47,,19.16,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,8.1,
CARDIZEM CD 240MG,5010105,CDM,259,RC,,,Outpatient,,,12.00,12.00,,7.05,58.75,,41.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,41.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,48.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,1425.6,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,1425.6,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,41.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,47,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,19.16,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
METRONIDAZOLE 250MG,5010112,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,82.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,82.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,1613.52,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,1613.52,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,82.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,1.52,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,9.216,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
MORPHINE 10 MG H,5010116,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,427.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,427.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,12.576,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
MORPHINE 15MG H,5010117,CDM,250,RC,,,Outpatient,,,25.00,25.00,,14.69,58.75,,907.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.69,58.75,,907.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.1,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,14.69,58.75,,907.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.75,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,22.5,
MORPHINE 8MG H,5010121,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,38.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,37.6,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
NUBAIN 10MG/ML 1ML,5010122,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,5.096,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
NUBAIN 20MG/2MLAMP,5010124,CDM,250,RC,,,Outpatient,,,28.00,28.00,,16.45,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,3.456,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,25.2,
PAVULON 1MG/ML 10ML,5010130,CDM,250,RC,,,Outpatient,,,106.50,106.50,,62.57,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.57,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.56,48.41,,31.76,Percent of Total Billed Charges,48.41% of Total Billed Charges,95.85,90,,76.68,Percent of Total Billed Charges,90% of Total Billed Charges,95.85,90,,76.68,Percent of Total Billed Charges,90% of Total Billed Charges,50.06,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,95.85,90,,76.68,Percent of Total Billed Charges,90% of Total Billed Charges,62.57,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,50.06,47,,30.832,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,50.06,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,50.06,47,,14.76,Percent of Total Billed Charges,47% of Total Billed Charges,50.06,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,50.06,95.85,
QUELICIN H 100MG/ML,5010143,CDM,250,RC,,,Outpatient,,,40.70,40.70,,23.91,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.91,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.7,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,36.63,90,,29.304,Percent of Total Billed Charges,90% of Total Billed Charges,36.63,90,,29.304,Percent of Total Billed Charges,90% of Total Billed Charges,19.13,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,36.63,90,,29.304,Percent of Total Billed Charges,90% of Total Billed Charges,23.91,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.13,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,19.13,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.13,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,19.13,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,19.13,36.63,
ANECTINE 10ML-200MG,5010146,CDM,250,RC,,,Outpatient,,,32.00,32.00,,18.8,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,15.04,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,28.8,
MARCAINE 0.25% 30ML,5010176,CDM,250,RC,,,Outpatient,,,28.00,28.00,,16.45,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,12.48,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,25.2,
MARCAINE .5% 10ML H,5010181,CDM,250,RC,,,Outpatient,,,28.00,28.00,,16.45,58.75,,28.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,28.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,22.464,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,58.75,,28.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,21.808,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,88.08,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,25.2,
MARCAINE 0.5% PER ML,5010182,CDM,250,RC,,,Outpatient,,,28.00,28.00,,16.45,58.75,,28.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,28.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,58.75,,28.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,19.16,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,25.2,
MARCAINE .75% 30A,5010185,CDM,250,RC,,,Outpatient,,,28.00,28.00,,16.45,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,19.16,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,25.2,
"MARCAINE,EPI 0.75%",5010188,CDM,250,RC,,,Outpatient,,,32.00,32.00,,18.8,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,14.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,15.04,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,14.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,9.216,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,28.8,
COVERA 240,5010189,CDM,259,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,12.576,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
ZOSYN 3.375GM,5010194,CDM,250,RC,,,Outpatient,,,218.00,218.00,,128.08,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,128.08,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,105.53,48.41,,81.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,196.2,90,,156.96,Percent of Total Billed Charges,90% of Total Billed Charges,196.2,90,,156.96,Percent of Total Billed Charges,90% of Total Billed Charges,102.46,47,,79.336,Percent of Total Billed Charges,47% of Total Billed Charges,196.2,90,,156.96,Percent of Total Billed Charges,90% of Total Billed Charges,128.08,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,102.46,47,,79.336,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,102.46,47,,79.336,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,102.46,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,102.46,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,102.46,196.2,
TRACRIUM INJ 50MG,5010195,CDM,250,RC,,,Outpatient,,,119.00,119.00,,69.91,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.91,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.61,48.41,,41.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.1,90,,85.68,Percent of Total Billed Charges,90% of Total Billed Charges,107.1,90,,85.68,Percent of Total Billed Charges,90% of Total Billed Charges,55.93,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,107.1,90,,85.68,Percent of Total Billed Charges,90% of Total Billed Charges,69.91,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.93,47,,39.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,55.93,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.93,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,55.93,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,55.93,107.1,
"MARCAINE,EPI 0.5% PER ML",5010225,CDM,250,RC,,,Outpatient,,,30.00,30.00,,17.63,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.63,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.52,48.41,,63.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,27,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,27,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,27,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,17.63,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,62.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.1,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,27,
"MARCAINE,EPI 0.25%",5010227,CDM,250,RC,,,Outpatient,,,32.00,32.00,,18.8,58.75,,36.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,36.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,34.464,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,15.04,47,,33.464,Percent of Total Billed Charges,47% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,58.75,,36.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,33.464,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,33.464,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,28.8,
LEVAQUIN 500MG IV,5011008,CDM,250,RC,,,Outpatient,,,281.00,281.00,,165.09,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,165.09,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,136.03,48.41,,18.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,252.9,90,,202.32,Percent of Total Billed Charges,90% of Total Billed Charges,252.9,90,,202.32,Percent of Total Billed Charges,90% of Total Billed Charges,132.07,47,,18.24,Percent of Total Billed Charges,47% of Total Billed Charges,252.9,90,,202.32,Percent of Total Billed Charges,90% of Total Billed Charges,165.09,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,132.07,47,,18.24,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,132.07,47,,18.24,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,132.07,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,132.07,47,,39.328,Percent of Total Billed Charges,47% of Total Billed Charges,132.07,252.9,
THORAZINE 25-50MG IM,5011009,CDM,250,RC,,,Outpatient,,,33.00,33.00,,19.39,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.39,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.98,48.41,,162.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,29.7,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,29.7,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,15.51,47,,157.92,Percent of Total Billed Charges,47% of Total Billed Charges,29.7,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,19.39,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,157.92,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.51,47,,157.92,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,29.7,
VALIUM 10MG SYRINGE,5011014,CDM,250,RC,,,Outpatient,,,109.00,109.00,,64.04,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.04,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,52.77,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,98.1,90,,78.48,Percent of Total Billed Charges,90% of Total Billed Charges,98.1,90,,78.48,Percent of Total Billed Charges,90% of Total Billed Charges,51.23,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,98.1,90,,78.48,Percent of Total Billed Charges,90% of Total Billed Charges,64.04,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,51.23,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,51.23,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,51.23,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,51.23,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,51.23,98.1,
DOXYCYCLINE 100MG IN,5011018,CDM,250,RC,,,Outpatient,,,83.00,83.00,,48.76,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.76,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.18,48.41,,29.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,74.7,90,,59.76,Percent of Total Billed Charges,90% of Total Billed Charges,74.7,90,,59.76,Percent of Total Billed Charges,90% of Total Billed Charges,39.01,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,74.7,90,,59.76,Percent of Total Billed Charges,90% of Total Billed Charges,48.76,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,39.01,47,,28.2,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,39.01,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,39.01,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,39.01,47,,41.368,Percent of Total Billed Charges,47% of Total Billed Charges,39.01,74.7,
PREMARIN 0.625MG,5011024,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,70.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,70.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,70.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,43.992,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PRECACID 15MG CAP,5011025,CDM,250,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,43.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,43.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,213.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,207.552,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,43.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,207.552,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,207.552,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
HALDOL 5MG/CC 1CC,5011029,CDM,250,RC,,,Outpatient,,,37.00,37.00,,21.74,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.74,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.91,48.41,,28.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,33.3,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,33.3,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,17.39,47,,27.824,Percent of Total Billed Charges,47% of Total Billed Charges,33.3,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,21.74,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.39,47,,27.824,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.39,47,,27.824,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.39,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,17.39,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,17.39,33.3,
VISTARIL INJ 100MG G,5011030,CDM,250,RC,,,Outpatient,,,54.00,54.00,,31.73,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.73,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,26.14,48.41,,53.056,Percent of Total Billed Charges,48.41% of Total Billed Charges,48.6,90,,38.88,Percent of Total Billed Charges,90% of Total Billed Charges,48.6,90,,38.88,Percent of Total Billed Charges,90% of Total Billed Charges,25.38,47,,51.512,Percent of Total Billed Charges,47% of Total Billed Charges,48.6,90,,38.88,Percent of Total Billed Charges,90% of Total Billed Charges,31.73,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,25.38,47,,51.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,25.38,47,,51.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,25.38,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,25.38,47,,10.4,Percent of Total Billed Charges,47% of Total Billed Charges,25.38,48.6,
VISTARIL 25MG HGENE,5011032,CDM,250,RC,,,Outpatient,,,88.00,88.00,,51.7,58.75,,45.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.7,58.75,,45.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.6,48.41,,38.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,79.2,90,,63.36,Percent of Total Billed Charges,90% of Total Billed Charges,79.2,90,,63.36,Percent of Total Billed Charges,90% of Total Billed Charges,41.36,47,,37.224,Percent of Total Billed Charges,47% of Total Billed Charges,79.2,90,,63.36,Percent of Total Billed Charges,90% of Total Billed Charges,51.7,58.75,,45.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,41.36,47,,37.224,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,41.36,47,,37.224,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,41.36,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,41.36,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,41.36,79.2,
VISTARIL INJ,5011035,CDM,250,RC,,,Outpatient,,,176.00,176.00,,103.4,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,103.4,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,85.2,48.41,,53.056,Percent of Total Billed Charges,48.41% of Total Billed Charges,158.4,90,,126.72,Percent of Total Billed Charges,90% of Total Billed Charges,158.4,90,,126.72,Percent of Total Billed Charges,90% of Total Billed Charges,82.72,47,,51.512,Percent of Total Billed Charges,47% of Total Billed Charges,158.4,90,,126.72,Percent of Total Billed Charges,90% of Total Billed Charges,103.4,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,82.72,47,,51.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,82.72,47,,51.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,82.72,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,82.72,47,,10.568,Percent of Total Billed Charges,47% of Total Billed Charges,82.72,158.4,
LORAZEPAM 2 MG INJ,5011038,CDM,250,RC,,,Outpatient,,,25.00,25.00,,14.69,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.69,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.1,48.41,,13.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,14.69,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,13.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.75,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,47,,22.952,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,22.5,
LUPRON,5011049,CDM,250,RC,,,Outpatient,,,1931.00,1931.00,,1134.46,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,1134.46,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,934.8,48.41,,84.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,1737.9,90,,1390.32,Percent of Total Billed Charges,90% of Total Billed Charges,1737.9,90,,1390.32,Percent of Total Billed Charges,90% of Total Billed Charges,907.57,47,,81.968,Percent of Total Billed Charges,47% of Total Billed Charges,1737.9,90,,1390.32,Percent of Total Billed Charges,90% of Total Billed Charges,1134.46,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,907.57,47,,81.968,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,907.57,47,,81.968,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,907.57,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,907.57,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,907.57,1737.9,
PHENOBARB TAB 60 MG,5011052,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,11.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,11.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,11.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DILANTIN 100MG INJ,5011054,CDM,250,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,39.328,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
DILANTIN 250 MGINJ,5011056,CDM,250,RC,,,Outpatient,,,38.00,38.00,,22.33,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.33,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.4,48.41,,8.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,34.2,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,34.2,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,34.2,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,22.33,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,8.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.86,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,47,,2.824,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,34.2,
VERAPAMIL 80MG TAB,5011075,CDM,250,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,18.216,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,18.216,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,15.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,18.216,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,15.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,4.608,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
LANOXIN 0.5MG/2ML H,5012015,CDM,250,RC,,,Outpatient,,,20.90,20.90,,12.28,58.75,,22.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.28,58.75,,22.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.12,48.41,,11.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,9.82,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,12.28,58.75,,22.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,11.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.82,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,41.368,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,47,,13.728,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,18.81,
DOCUSATE CALCIUM 240,5012018,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,41.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,41.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,41.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,43.992,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ADRENALIN 1ML H,5012034,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,64.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,64.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,26.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,64.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,25.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
EPI 1/10000 10ML CAR,5012037,CDM,250,RC,,,Outpatient,,,60.00,60.00,,35.25,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.25,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.05,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,54,90,,43.2,Percent of Total Billed Charges,90% of Total Billed Charges,54,90,,43.2,Percent of Total Billed Charges,90% of Total Billed Charges,28.2,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,54,90,,43.2,Percent of Total Billed Charges,90% of Total Billed Charges,35.25,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.2,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.2,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.2,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,28.2,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,28.2,54,
EPI INJ,5012039,CDM,250,RC,,,Outpatient,,,60.00,60.00,,35.25,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.25,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.05,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,54,90,,43.2,Percent of Total Billed Charges,90% of Total Billed Charges,54,90,,43.2,Percent of Total Billed Charges,90% of Total Billed Charges,28.2,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,54,90,,43.2,Percent of Total Billed Charges,90% of Total Billed Charges,35.25,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.2,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.2,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.2,47,,10.4,Percent of Total Billed Charges,47% of Total Billed Charges,28.2,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,28.2,54,
LASIX 20MG/2ML,5012044,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,25.176,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,24.44,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,24.44,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,24.44,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
LASIX INJ 20MG/2ML,5012045,CDM,250,RC,,,Outpatient,,,26.00,26.00,,15.28,58.75,,58.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.28,58.75,,58.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.59,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,23.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,23.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,12.22,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,23.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,15.28,58.75,,58.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.22,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.22,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.22,47,,10.568,Percent of Total Billed Charges,47% of Total Billed Charges,12.22,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,12.22,23.4,
LASIX 40MG/4ML AMP,5012047,CDM,250,RC,,,Outpatient,,,20.90,20.90,,12.28,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.28,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.12,48.41,,55.384,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,9.82,47,,53.768,Percent of Total Billed Charges,47% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,12.28,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,53.768,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.82,47,,53.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,22.952,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,18.81,
ISUPREL 0.2MG/ML,5012052,CDM,250,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,110.376,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,107.16,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,107.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,107.16,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,147.344,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
ISUPREL 1/5000 5ML,5012054,CDM,250,RC,,,Outpatient,,,51.00,51.00,,29.96,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.96,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.69,48.41,,22,Percent of Total Billed Charges,48.41% of Total Billed Charges,45.9,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,45.9,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,23.97,47,,21.36,Percent of Total Billed Charges,47% of Total Billed Charges,45.9,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,29.96,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,21.36,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.97,47,,21.36,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,47,,256.056,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,45.9,
VASOTEC 10MG,5012059,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,39.888,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,38.728,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,38.728,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,38.728,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,524.52,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
XYLOCAINE 2GM IV CAR,5012068,CDM,250,RC,,,Outpatient,,,77.00,77.00,,45.24,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.24,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.28,48.41,,18.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,69.3,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,69.3,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,36.19,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,69.3,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,45.24,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,36.19,47,,17.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,36.19,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,36.19,47,,2.824,Percent of Total Billed Charges,47% of Total Billed Charges,36.19,47,,36.528,Percent of Total Billed Charges,47% of Total Billed Charges,36.19,69.3,
VASERETIC,5012080,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,8.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,4.608,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,460.416,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
ADVIL SUSP 1 DOSE,5012081,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,23.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,38.544,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,13.728,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,144.76,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
NITROBID 50MG 10ML H,5012083,CDM,250,RC,,,Outpatient,,,32.00,32.00,,18.8,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,10.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,15.04,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,9.776,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,47,,103.144,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,28.8,
NITROSTAT TAB,5012087,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,744.48,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
NITROSTAT IV KIT,5012089,CDM,250,RC,,,Outpatient,,,150.00,150.00,,88.13,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,88.13,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,72.62,48.41,,9.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,135,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,135,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,70.5,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,135,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,88.13,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,70.5,47,,9.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,70.5,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,70.5,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,70.5,47,,136.488,Percent of Total Billed Charges,47% of Total Billed Charges,70.5,135,
NITROBID 50 MG IV PREMIX,5012090,CDM,250,RC,,,Outpatient,,,93.00,93.00,,54.64,58.75,,27.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,54.64,58.75,,27.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.02,48.41,,20.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,83.7,90,,66.96,Percent of Total Billed Charges,90% of Total Billed Charges,83.7,90,,66.96,Percent of Total Billed Charges,90% of Total Billed Charges,43.71,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,83.7,90,,66.96,Percent of Total Billed Charges,90% of Total Billed Charges,54.64,58.75,,27.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,43.71,47,,19.552,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,43.71,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,43.71,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,43.71,47,,842.616,Percent of Total Billed Charges,47% of Total Billed Charges,43.71,83.7,
PROCAINAMIDE 100 MG,5012099,CDM,259,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,8.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,223.344,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
PROCAINAMIDE 1000MG,5012101,CDM,259,RC,,,Outpatient,,,38.00,38.00,,22.33,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.33,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.4,48.41,,37.176,Percent of Total Billed Charges,48.41% of Total Billed Charges,34.2,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,34.2,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,34.2,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,22.33,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,36.096,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.86,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,34.2,
QUINIDINE GLUC 10ML,5012103,CDM,250,RC,,,Outpatient,,,96.00,96.00,,56.4,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,56.4,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.47,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,86.4,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,86.4,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,45.12,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,86.4,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,56.4,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.12,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,45.12,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.12,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,45.12,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,45.12,86.4,
VERAPAMIL 10MG/4ML,5012112,CDM,250,RC,,,Outpatient,,,28.00,28.00,,16.45,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,147.344,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,25.2,
EPHEDRINE 50MG H,5012114,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,99.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,99.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,99.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,256.056,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
BUMEX 0.5MG/2MLH,5012118,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,49.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,49.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,147.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,143.256,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,49.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,143.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,143.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,524.52,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
LOPRESSOR 5MG VIAL,5012119,CDM,250,RC,,,Outpatient,,,25.30,25.30,,14.86,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.86,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.25,48.41,,17.04,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.77,90,,18.216,Percent of Total Billed Charges,90% of Total Billed Charges,22.77,90,,18.216,Percent of Total Billed Charges,90% of Total Billed Charges,11.89,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,22.77,90,,18.216,Percent of Total Billed Charges,90% of Total Billed Charges,14.86,58.75,,77.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.89,47,,16.544,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.89,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.89,47,,36.528,Percent of Total Billed Charges,47% of Total Billed Charges,11.89,47,,9.512,Percent of Total Billed Charges,47% of Total Billed Charges,11.89,22.77,
NORMODYNE 100MGINJ,5012143,CDM,250,RC,,,Outpatient,,,69.00,69.00,,40.54,58.75,,41.832,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.54,58.75,,41.832,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.4,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,62.1,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,62.1,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,32.43,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,62.1,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,40.54,58.75,,41.832,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.43,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,32.43,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.43,47,,460.416,Percent of Total Billed Charges,47% of Total Billed Charges,32.43,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,32.43,62.1,
ZYRTEC 10MG TAB,5013001,CDM,250,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,22.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,22.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,31.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,31.024,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,22.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,31.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,31.024,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,144.76,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
AMPICIL 1GM INJ,5013010,CDM,250,RC,,,Outpatient,,,38.75,38.75,,22.77,58.75,,197.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.77,58.75,,197.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.76,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,34.88,90,,27.904,Percent of Total Billed Charges,90% of Total Billed Charges,34.88,90,,27.904,Percent of Total Billed Charges,90% of Total Billed Charges,18.21,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,34.88,90,,27.904,Percent of Total Billed Charges,90% of Total Billed Charges,22.77,58.75,,197.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.21,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.21,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.21,47,,103.144,Percent of Total Billed Charges,47% of Total Billed Charges,18.21,47,,14.568,Percent of Total Billed Charges,47% of Total Billed Charges,18.21,34.88,
KEFZOL 1GM,5013040,CDM,250,RC,,,Outpatient,,,47.50,47.50,,27.91,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.91,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.99,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.75,90,,34.2,Percent of Total Billed Charges,90% of Total Billed Charges,42.75,90,,34.2,Percent of Total Billed Charges,90% of Total Billed Charges,22.33,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,42.75,90,,34.2,Percent of Total Billed Charges,90% of Total Billed Charges,27.91,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.33,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,22.33,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.33,47,,744.48,Percent of Total Billed Charges,47% of Total Billed Charges,22.33,47,,17.864,Percent of Total Billed Charges,47% of Total Billed Charges,22.33,42.75,
MEFOXIN 1GM INJ,5013048,CDM,250,RC,,,Outpatient,,,88.00,88.00,,51.7,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.7,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.6,48.41,,11.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,79.2,90,,63.36,Percent of Total Billed Charges,90% of Total Billed Charges,79.2,90,,63.36,Percent of Total Billed Charges,90% of Total Billed Charges,41.36,47,,11.376,Percent of Total Billed Charges,47% of Total Billed Charges,79.2,90,,63.36,Percent of Total Billed Charges,90% of Total Billed Charges,51.7,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,41.36,47,,11.376,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,41.36,47,,11.376,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,41.36,47,,136.488,Percent of Total Billed Charges,47% of Total Billed Charges,41.36,47,,33.088,Percent of Total Billed Charges,47% of Total Billed Charges,41.36,79.2,
MEFOXIN 2GM INJH,5013049,CDM,250,RC,,,Outpatient,,,138.00,138.00,,81.08,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,81.08,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.81,48.41,,9.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,124.2,90,,99.36,Percent of Total Billed Charges,90% of Total Billed Charges,124.2,90,,99.36,Percent of Total Billed Charges,90% of Total Billed Charges,64.86,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,124.2,90,,99.36,Percent of Total Billed Charges,90% of Total Billed Charges,81.08,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,64.86,47,,9.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,64.86,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,64.86,47,,842.616,Percent of Total Billed Charges,47% of Total Billed Charges,64.86,47,,51.888,Percent of Total Billed Charges,47% of Total Billed Charges,64.86,124.2,
CLEOCIN 300MG INJ,5013076,CDM,250,RC,,,Outpatient,,,38.00,38.00,,22.33,58.75,,259.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.33,58.75,,259.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.4,48.41,,10.224,Percent of Total Billed Charges,48.41% of Total Billed Charges,34.2,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,34.2,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,47,,9.928,Percent of Total Billed Charges,47% of Total Billed Charges,34.2,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,22.33,58.75,,259.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,9.928,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.86,47,,9.928,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,223.344,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,34.2,
CLEOCIN 600MG H,5013077,CDM,250,RC,,,Outpatient,,,51.00,51.00,,29.96,58.75,,34.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.96,58.75,,34.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.69,48.41,,24.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,45.9,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,45.9,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,23.97,47,,24.16,Percent of Total Billed Charges,47% of Total Billed Charges,45.9,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,29.96,58.75,,34.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,24.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.97,47,,24.16,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,45.9,
VIBRAMYCIN 100MG H,5013081,CDM,250,RC,,,Outpatient,,,64.00,64.00,,37.6,58.75,,64.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.6,58.75,,64.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.98,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,57.6,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,57.6,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,30.08,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,57.6,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,37.6,58.75,,64.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.08,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,30.08,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.08,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,30.08,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,30.08,57.6,
VIBRAMYCIN 200MG,5013082,CDM,259,RC,,,Outpatient,,,125.00,125.00,,73.44,58.75,,46.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.44,58.75,,46.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,60.51,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,112.5,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,112.5,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,58.75,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,112.5,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,73.44,58.75,,46.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,58.75,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,58.75,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,58.75,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,58.75,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,58.75,112.5,
DOSS 100 MG CAP,5013084,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,64.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,64.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,64.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
IBUPROFEN 400MGO,5013086,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,16.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,16.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,16.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
IBUPROFEN 600MG,5013087,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,102.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,102.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,102.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
GENTAMYCIN OPHTH OINT/SOLN,5013098,CDM,270,RC,,,Outpatient,,,100.00,100.00,,58.75,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.75,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.41,48.41,,8.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,90,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,90,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,47,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,90,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,58.75,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47,47,,8.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,47,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,47,90,
GARAMYCIN 60MG/1.5ML,5013100,CDM,250,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
GARAMYCIN 40 MGINJ,5013101,CDM,250,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,27.496,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,26.696,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
FLU VACCINE 0.5ML H,5013113,CDM,250,RC,,,Outpatient,,,82.00,82.00,,48.18,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.18,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.7,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,73.8,90,,59.04,Percent of Total Billed Charges,90% of Total Billed Charges,73.8,90,,59.04,Percent of Total Billed Charges,90% of Total Billed Charges,38.54,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,73.8,90,,59.04,Percent of Total Billed Charges,90% of Total Billed Charges,48.18,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.54,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,38.54,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.54,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,38.54,47,,30.832,Percent of Total Billed Charges,47% of Total Billed Charges,38.54,73.8,
ISOSORBIDE 5MG O,5013117,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ISOSORBIDE 10MG,5013118,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ISOSORBIDE 20MGO,5013119,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,31.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,31.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,8.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,31.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.896,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
FLAGYL 500MG RTU H,5013132,CDM,250,RC,,,Outpatient,,,58.00,58.00,,34.08,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.08,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.08,48.41,,17.04,Percent of Total Billed Charges,48.41% of Total Billed Charges,52.2,90,,41.76,Percent of Total Billed Charges,90% of Total Billed Charges,52.2,90,,41.76,Percent of Total Billed Charges,90% of Total Billed Charges,27.26,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,52.2,90,,41.76,Percent of Total Billed Charges,90% of Total Billed Charges,34.08,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.26,47,,16.544,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,27.26,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.26,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,27.26,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,27.26,52.2,
MOTRIN 800MG,5013139,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,12.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,12.408,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
MS CONTIN 30MG TAB,5013140,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,30.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,30.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,10.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,10.344,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,30.552,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,10.344,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,10.344,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
UNISYN INJ 1.5GM,5013145,CDM,250,RC,,,Outpatient,,,38.00,38.00,,22.33,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.33,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.4,48.41,,25.944,Percent of Total Billed Charges,48.41% of Total Billed Charges,34.2,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,34.2,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,47,,25.192,Percent of Total Billed Charges,47% of Total Billed Charges,34.2,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,22.33,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,25.192,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.86,47,,25.192,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,34.2,
NIACIN 250 MG CAP,5013152,CDM,250,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,67.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,67.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,54.216,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,52.64,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,67.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,52.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,52.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TERAZOL VAG SUPP BX,5013163,CDM,259,RC,,,Outpatient,,,211.00,211.00,,123.96,58.75,,133.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,123.96,58.75,,133.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,102.15,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,189.9,90,,151.92,Percent of Total Billed Charges,90% of Total Billed Charges,189.9,90,,151.92,Percent of Total Billed Charges,90% of Total Billed Charges,99.17,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,189.9,90,,151.92,Percent of Total Billed Charges,90% of Total Billed Charges,123.96,58.75,,133.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,99.17,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,99.17,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,99.17,47,,79.336,Percent of Total Billed Charges,47% of Total Billed Charges,99.17,47,,79.336,Percent of Total Billed Charges,47% of Total Billed Charges,99.17,189.9,
BICILLIN CR 1.2MUL,5013170,CDM,250,RC,,,Outpatient,,,106.00,106.00,,62.28,58.75,,26.696,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.28,58.75,,26.696,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.31,48.41,,5.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,95.4,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,95.4,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,49.82,47,,5.792,Percent of Total Billed Charges,47% of Total Billed Charges,95.4,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,62.28,58.75,,21.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.82,47,,5.792,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,49.82,47,,5.792,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.82,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,49.82,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,49.82,95.4,
BICILLIN CR 2.4MUL,5013171,CDM,250,RC,,,Outpatient,,,165.00,165.00,,96.94,58.75,,48.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.94,58.75,,48.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.88,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,148.5,90,,118.8,Percent of Total Billed Charges,90% of Total Billed Charges,148.5,90,,118.8,Percent of Total Billed Charges,90% of Total Billed Charges,77.55,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,148.5,90,,118.8,Percent of Total Billed Charges,90% of Total Billed Charges,96.94,58.75,,48.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.55,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,77.55,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.55,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,77.55,47,,62.04,Percent of Total Billed Charges,47% of Total Billed Charges,77.55,148.5,
BICILLIN CR 600000 H,5013172,CDM,250,RC,,,Outpatient,,,89.00,89.00,,52.29,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,52.29,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,43.08,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,80.1,90,,64.08,Percent of Total Billed Charges,90% of Total Billed Charges,80.1,90,,64.08,Percent of Total Billed Charges,90% of Total Billed Charges,41.83,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,80.1,90,,64.08,Percent of Total Billed Charges,90% of Total Billed Charges,52.29,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,41.83,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,41.83,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,41.83,47,,33.464,Percent of Total Billed Charges,47% of Total Billed Charges,41.83,47,,33.464,Percent of Total Billed Charges,47% of Total Billed Charges,41.83,80.1,
BICILLIN LA 1.2MIL,5013174,CDM,250,RC,,,Outpatient,,,48.50,48.50,,28.49,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.49,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.48,48.41,,10.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,43.65,90,,34.92,Percent of Total Billed Charges,90% of Total Billed Charges,43.65,90,,34.92,Percent of Total Billed Charges,90% of Total Billed Charges,22.8,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,43.65,90,,34.92,Percent of Total Billed Charges,90% of Total Billed Charges,28.49,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.8,47,,9.776,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,22.8,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.8,47,,18.24,Percent of Total Billed Charges,47% of Total Billed Charges,22.8,47,,18.24,Percent of Total Billed Charges,47% of Total Billed Charges,22.8,43.65,
PNEUMOVAX 23 VAC,5013196,CDM,250,RC,,,Outpatient,,,420.00,420.00,,246.75,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,246.75,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,203.32,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,378,90,,302.4,Percent of Total Billed Charges,90% of Total Billed Charges,378,90,,302.4,Percent of Total Billed Charges,90% of Total Billed Charges,197.4,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,378,90,,302.4,Percent of Total Billed Charges,90% of Total Billed Charges,246.75,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,197.4,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,197.4,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,197.4,47,,157.92,Percent of Total Billed Charges,47% of Total Billed Charges,197.4,47,,157.92,Percent of Total Billed Charges,47% of Total Billed Charges,197.4,378,
QUINIGLUTE TAB,5013202,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,8.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ROCEPHIN 125MG INJ,5013203,CDM,250,RC,,,Outpatient,,,75.00,75.00,,44.06,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.06,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.31,48.41,,82.104,Percent of Total Billed Charges,48.41% of Total Billed Charges,67.5,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,35.25,47,,79.712,Percent of Total Billed Charges,47% of Total Billed Charges,67.5,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,44.06,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.25,47,,79.712,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,35.25,47,,79.712,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.25,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,35.25,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,35.25,67.5,
SLOW FE TAB,5013206,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TET ANTITOXIN 20000,5013212,CDM,250,RC,,,Outpatient,,,552.00,552.00,,324.3,58.75,,24.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,324.3,58.75,,24.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,267.22,48.41,,33.304,Percent of Total Billed Charges,48.41% of Total Billed Charges,496.8,90,,397.44,Percent of Total Billed Charges,90% of Total Billed Charges,496.8,90,,397.44,Percent of Total Billed Charges,90% of Total Billed Charges,259.44,47,,32.336,Percent of Total Billed Charges,47% of Total Billed Charges,496.8,90,,397.44,Percent of Total Billed Charges,90% of Total Billed Charges,324.3,58.75,,24.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,259.44,47,,32.336,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,259.44,47,,32.336,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,259.44,47,,207.552,Percent of Total Billed Charges,47% of Total Billed Charges,259.44,47,,207.552,Percent of Total Billed Charges,47% of Total Billed Charges,259.44,496.8,
TET IMMUNE GLOBULIN,5013214,CDM,250,RC,,,Outpatient,,,74.00,74.00,,43.48,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,43.48,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.82,48.41,,115.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,66.6,90,,53.28,Percent of Total Billed Charges,90% of Total Billed Charges,66.6,90,,53.28,Percent of Total Billed Charges,90% of Total Billed Charges,34.78,47,,112.048,Percent of Total Billed Charges,47% of Total Billed Charges,66.6,90,,53.28,Percent of Total Billed Charges,90% of Total Billed Charges,43.48,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,34.78,47,,112.048,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,34.78,47,,112.048,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,34.78,47,,27.824,Percent of Total Billed Charges,47% of Total Billed Charges,34.78,47,,27.824,Percent of Total Billed Charges,47% of Total Billed Charges,34.78,66.6,
TDAP,5013215,CDM,250,RC,90715,HCPCS,Outpatient,,,137.00,137.00,,80.49,58.75,,45.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,80.49,58.75,,45.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.32,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,123.3,90,,98.64,Percent of Total Billed Charges,90% of Total Billed Charges,123.3,90,,98.64,Percent of Total Billed Charges,90% of Total Billed Charges,64.39,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,123.3,90,,98.64,Percent of Total Billed Charges,90% of Total Billed Charges,80.49,58.75,,45.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,64.39,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,64.39,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,64.39,47,,51.512,Percent of Total Billed Charges,47% of Total Billed Charges,64.39,47,,51.512,Percent of Total Billed Charges,47% of Total Billed Charges,64.39,123.3,
VANCOMYCIN 1GM INJ,5013237,CDM,250,RC,,,Outpatient,,,99.00,99.00,,58.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.93,48.41,,11.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,89.1,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,89.1,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,46.53,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,89.1,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,58.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.53,47,,11.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,46.53,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.53,47,,37.224,Percent of Total Billed Charges,47% of Total Billed Charges,46.53,47,,37.224,Percent of Total Billed Charges,47% of Total Billed Charges,46.53,89.1,
TDAP,5013244,CDM,636,RC,90715,HCPCS,Outpatient,,,137.00,137.00,,80.49,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,80.49,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.32,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,123.3,90,,98.64,Percent of Total Billed Charges,90% of Total Billed Charges,123.3,90,,98.64,Percent of Total Billed Charges,90% of Total Billed Charges,64.39,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,123.3,90,,98.64,Percent of Total Billed Charges,90% of Total Billed Charges,80.49,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,64.39,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,64.39,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,64.39,47,,51.512,Percent of Total Billed Charges,47% of Total Billed Charges,64.39,47,,51.512,Percent of Total Billed Charges,47% of Total Billed Charges,64.39,123.3,
GARAMYCIN 80MG/2ML,5013248,CDM,250,RC,,,Outpatient,,,35.00,35.00,,20.56,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.56,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.94,48.41,,30.984,Percent of Total Billed Charges,48.41% of Total Billed Charges,31.5,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,31.5,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,47,,30.08,Percent of Total Billed Charges,47% of Total Billed Charges,31.5,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,20.56,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.45,47,,30.08,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.45,47,,30.08,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.45,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,16.45,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,16.45,31.5,
ZITHROMAX (Z-PAK),5013255,CDM,250,RC,,,Outpatient,,,218.00,218.00,,128.08,58.75,,179.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,128.08,58.75,,179.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,105.53,48.41,,8.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,196.2,90,,156.96,Percent of Total Billed Charges,90% of Total Billed Charges,196.2,90,,156.96,Percent of Total Billed Charges,90% of Total Billed Charges,102.46,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,196.2,90,,156.96,Percent of Total Billed Charges,90% of Total Billed Charges,128.08,58.75,,179.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,102.46,47,,7.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,102.46,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,102.46,47,,81.968,Percent of Total Billed Charges,47% of Total Billed Charges,102.46,47,,81.968,Percent of Total Billed Charges,47% of Total Billed Charges,102.46,196.2,
SULFA-NETH/TRIMETH,5013257,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ROBINUL .2MG,5014011,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
REGLAN INJ 10MG/2ML,5014018,CDM,250,RC,,,Outpatient,,,23.00,23.00,,13.51,58.75,,38.776,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.51,58.75,,38.776,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.13,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,10.81,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,13.51,58.75,,38.776,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.81,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,20.7,
COMPAZINE 10MG/2ML,5014021,CDM,250,RC,,,Outpatient,,,40.00,40.00,,23.5,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.5,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.36,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,23.5,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.8,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,36,
TIGAN INJ 200MG/2ML,5014025,CDM,250,RC,,,Outpatient,,,30.00,30.00,,17.63,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.63,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.52,48.41,,8.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,27,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,27,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,27,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,17.63,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,7.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.1,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,27,
ACCUPRIL 10MG,5015018,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
LEVAQUIN 500MG TAB,5015024,CDM,259,RC,,,Outpatient,,,68.00,68.00,,39.95,58.75,,12.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.95,58.75,,12.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.92,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,61.2,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,61.2,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,31.96,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,61.2,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,39.95,58.75,,12.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.96,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.96,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.96,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,31.96,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,31.96,61.2,
ALBUTEROL SOLN UD 3M,5015040,CDM,250,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,30.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,30.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,30.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
DECADRON 4MG 1CC H,5016029,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,12.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,12.408,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
SOLU-CORTEF 1GM,5016050,CDM,250,RC,,,Outpatient,,,65.00,65.00,,38.19,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.19,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.47,48.41,,18.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,58.5,90,,46.8,Percent of Total Billed Charges,90% of Total Billed Charges,58.5,90,,46.8,Percent of Total Billed Charges,90% of Total Billed Charges,30.55,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,58.5,90,,46.8,Percent of Total Billed Charges,90% of Total Billed Charges,38.19,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.55,47,,17.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,30.55,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.55,47,,24.44,Percent of Total Billed Charges,47% of Total Billed Charges,30.55,47,,24.44,Percent of Total Billed Charges,47% of Total Billed Charges,30.55,58.5,
SOLU-CORTEF 100MG,5016051,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
SOLU-CORTEF 250MG,5016053,CDM,250,RC,,,Outpatient,,,143.00,143.00,,84.01,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.01,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.23,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,128.7,90,,102.96,Percent of Total Billed Charges,90% of Total Billed Charges,128.7,90,,102.96,Percent of Total Billed Charges,90% of Total Billed Charges,67.21,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,128.7,90,,102.96,Percent of Total Billed Charges,90% of Total Billed Charges,84.01,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,67.21,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,67.21,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,67.21,47,,53.768,Percent of Total Billed Charges,47% of Total Billed Charges,67.21,47,,53.768,Percent of Total Billed Charges,47% of Total Billed Charges,67.21,128.7,
SOLU-CORTEF 500MG,5016054,CDM,250,RC,,,Outpatient,,,285.00,285.00,,167.44,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,167.44,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,137.97,48.41,,178.536,Percent of Total Billed Charges,48.41% of Total Billed Charges,256.5,90,,205.2,Percent of Total Billed Charges,90% of Total Billed Charges,256.5,90,,205.2,Percent of Total Billed Charges,90% of Total Billed Charges,133.95,47,,173.336,Percent of Total Billed Charges,47% of Total Billed Charges,256.5,90,,205.2,Percent of Total Billed Charges,90% of Total Billed Charges,167.44,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,133.95,47,,173.336,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,133.95,47,,173.336,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,133.95,47,,107.16,Percent of Total Billed Charges,47% of Total Billed Charges,133.95,47,,107.16,Percent of Total Billed Charges,47% of Total Billed Charges,133.95,256.5,
DEPO-MEDROL 1CC,5016059,CDM,250,RC,J1010,HCPCS,Outpatient,1,UN,56.80,56.80,,33.37,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.37,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.5,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,51.12,90,,40.896,Percent of Total Billed Charges,90% of Total Billed Charges,51.12,90,,40.896,Percent of Total Billed Charges,90% of Total Billed Charges,26.7,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,51.12,90,,40.896,Percent of Total Billed Charges,90% of Total Billed Charges,26.7,47,,10.808,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.7,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.7,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.7,47,,21.36,Percent of Total Billed Charges,47% of Total Billed Charges,26.7,47,,21.36,Percent of Total Billed Charges,47% of Total Billed Charges,26.7,51.12,
SOLU-MEDROL 1000MG,5016061,CDM,250,RC,,,Outpatient,,,103.00,103.00,,60.51,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,60.51,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,49.86,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,92.7,90,,74.16,Percent of Total Billed Charges,90% of Total Billed Charges,92.7,90,,74.16,Percent of Total Billed Charges,90% of Total Billed Charges,48.41,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,92.7,90,,74.16,Percent of Total Billed Charges,90% of Total Billed Charges,60.51,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.41,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,48.41,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.41,47,,38.728,Percent of Total Billed Charges,47% of Total Billed Charges,48.41,47,,38.728,Percent of Total Billed Charges,47% of Total Billed Charges,48.41,92.7,
SOLU-MEDROL 125MG,5016062,CDM,250,RC,,,Outpatient,,,47.00,47.00,,27.61,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.61,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.75,48.41,,8.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,22.09,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,27.61,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,7.896,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,22.09,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,42.3,
SOLU-MEDROL 40MG,5016064,CDM,250,RC,,,Outpatient,,,20.90,20.90,,12.28,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.28,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.12,48.41,,21.688,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,9.82,47,,21.056,Percent of Total Billed Charges,47% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,12.28,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,21.056,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.82,47,,21.056,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,18.81,
SOLU-MEDROL 500MG,5016065,CDM,250,RC,,,Outpatient,,,61.00,61.00,,35.84,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.84,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.53,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,54.9,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,28.67,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,54.9,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,35.84,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.67,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,54.9,
CALCIUM CHLOR 10ML,5017023,CDM,250,RC,,,Outpatient,,,26.00,26.00,,15.28,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.28,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.59,48.41,,5.112,Percent of Total Billed Charges,48.41% of Total Billed Charges,23.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,23.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,12.22,47,,4.96,Percent of Total Billed Charges,47% of Total Billed Charges,23.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,15.28,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.22,47,,4.96,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.22,47,,4.96,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.22,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,12.22,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,12.22,23.4,
CALAN SR 240MG O,5017024,CDM,259,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
CYANOCOBAL 1000MCG,5017040,CDM,250,RC,,,Outpatient,,,25.00,25.00,,14.69,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.69,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.1,48.41,,725.376,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,47,,704.248,Percent of Total Billed Charges,47% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,14.69,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,704.248,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.75,47,,704.248,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,22.5,
DEXTROSE 50% 50ML,5017044,CDM,250,RC,,,Outpatient,,,52.00,52.00,,30.55,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.55,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.17,48.41,,718.016,Percent of Total Billed Charges,48.41% of Total Billed Charges,46.8,90,,37.44,Percent of Total Billed Charges,90% of Total Billed Charges,46.8,90,,37.44,Percent of Total Billed Charges,90% of Total Billed Charges,24.44,47,,697.104,Percent of Total Billed Charges,47% of Total Billed Charges,46.8,90,,37.44,Percent of Total Billed Charges,90% of Total Billed Charges,30.55,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.44,47,,697.104,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,24.44,47,,697.104,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.44,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,24.44,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,24.44,46.8,
TUBERSOL,5017045,CDM,250,RC,,,Outpatient,,,20.90,20.90,,12.28,58.75,,12.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.28,58.75,,12.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.12,48.41,,71.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,9.82,47,,69.56,Percent of Total Billed Charges,47% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,12.28,58.75,,12.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,69.56,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.82,47,,69.56,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,18.81,
PREMARIN 25MG H,5017062,CDM,250,RC,,,Outpatient,,,96.00,96.00,,56.4,58.75,,31.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,56.4,58.75,,31.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.47,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,86.4,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,86.4,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,45.12,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,86.4,90,,69.12,Percent of Total Billed Charges,90% of Total Billed Charges,56.4,58.75,,31.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.12,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,45.12,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.12,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,45.12,47,,36.096,Percent of Total Billed Charges,47% of Total Billed Charges,45.12,86.4,
THEO-24 200MG CAP,5017064,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,65.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,65.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,65.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
THEO-24 300MG CAP,5017065,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
FUROSEMIDE 80MGO,5017070,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,7.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,7.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,7.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
GLUCAGON 1 UNITH,5017072,CDM,250,RC,,,Outpatient,,,381.00,381.00,,223.84,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,223.84,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,184.44,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,342.9,90,,274.32,Percent of Total Billed Charges,90% of Total Billed Charges,342.9,90,,274.32,Percent of Total Billed Charges,90% of Total Billed Charges,179.07,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,342.9,90,,274.32,Percent of Total Billed Charges,90% of Total Billed Charges,223.84,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,179.07,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,179.07,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,179.07,47,,143.256,Percent of Total Billed Charges,47% of Total Billed Charges,179.07,47,,143.256,Percent of Total Billed Charges,47% of Total Billed Charges,179.07,342.9,
INSULIN INJ (ANY ER),5017099,CDM,250,RC,,,Outpatient,,,44.00,44.00,,25.85,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.85,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.3,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,20.68,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,25.85,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,20.68,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,20.68,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,20.68,39.6,
GUIATUSS SYR 4OZ,5017114,CDM,259,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
INFED INJ 50 MG,5017116,CDM,250,RC,,,Outpatient,,,82.50,82.50,,48.47,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.47,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.94,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,74.25,90,,59.4,Percent of Total Billed Charges,90% of Total Billed Charges,74.25,90,,59.4,Percent of Total Billed Charges,90% of Total Billed Charges,38.78,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,74.25,90,,59.4,Percent of Total Billed Charges,90% of Total Billed Charges,48.47,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.78,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,38.78,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.78,47,,31.024,Percent of Total Billed Charges,47% of Total Billed Charges,38.78,47,,31.024,Percent of Total Billed Charges,47% of Total Billed Charges,38.78,74.25,
LOZOL 2.5MG TAB,5017127,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MAXZIDE TAB,5017132,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,99.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,99.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,99.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
MAG SULF 50% 10ML,5017133,CDM,250,RC,,,Outpatient,,,30.25,30.25,,17.77,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.77,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.64,48.41,,165.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,27.23,90,,21.784,Percent of Total Billed Charges,90% of Total Billed Charges,27.23,90,,21.784,Percent of Total Billed Charges,90% of Total Billed Charges,14.22,47,,160.928,Percent of Total Billed Charges,47% of Total Billed Charges,27.23,90,,21.784,Percent of Total Billed Charges,90% of Total Billed Charges,17.77,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.22,47,,160.928,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.22,47,,160.928,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.22,47,,11.376,Percent of Total Billed Charges,47% of Total Billed Charges,14.22,47,,11.376,Percent of Total Billed Charges,47% of Total Billed Charges,14.22,27.23,
MAG SULF 50% 2ML H,5017134,CDM,250,RC,,,Outpatient,,,25.00,25.00,,14.69,58.75,,40.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.69,58.75,,40.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.1,48.41,,29.824,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,47,,28.952,Percent of Total Billed Charges,47% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,14.69,58.75,,40.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,28.952,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.75,47,,28.952,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,22.5,
MVI CONCENTRATE5ML,5017150,CDM,259,RC,,,Outpatient,,,26.40,26.40,,15.51,58.75,,140.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.51,58.75,,140.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.78,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,23.76,90,,19.008,Percent of Total Billed Charges,90% of Total Billed Charges,23.76,90,,19.008,Percent of Total Billed Charges,90% of Total Billed Charges,12.41,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,23.76,90,,19.008,Percent of Total Billed Charges,90% of Total Billed Charges,15.51,58.75,,140.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.41,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.41,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.41,47,,9.928,Percent of Total Billed Charges,47% of Total Billed Charges,12.41,47,,9.928,Percent of Total Billed Charges,47% of Total Billed Charges,12.41,23.76,
MVI-12 INJ,5017151,CDM,250,RC,,,Outpatient,,,64.25,64.25,,37.75,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.75,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.1,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,57.83,90,,46.264,Percent of Total Billed Charges,90% of Total Billed Charges,57.83,90,,46.264,Percent of Total Billed Charges,90% of Total Billed Charges,30.2,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,57.83,90,,46.264,Percent of Total Billed Charges,90% of Total Billed Charges,37.75,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.2,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,30.2,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.2,47,,24.16,Percent of Total Billed Charges,47% of Total Billed Charges,30.2,47,,24.16,Percent of Total Billed Charges,47% of Total Billed Charges,30.2,57.83,
PITOCIN AMP IOU1ML,5017160,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,9.376,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,9.096,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,9.096,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,9.096,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
PITOCIN IOU SYRINGE,5017161,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,99.92,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,97.008,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,97.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,97.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
POT ACET 40MEQ/20ML,5017169,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,37.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,37.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,37.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
POT CL 20MEQ/10ML,5017171,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
POT CL 30MEQ/15ML,5017173,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,8.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
POT CL 40MEQ/20ML,5017174,CDM,250,RC,,,Outpatient,,,23.00,23.00,,13.51,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.51,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.13,48.41,,16.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,10.81,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,13.51,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,15.792,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.81,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,20.7,
PYRIDOXINE 100MG/ML,5017188,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
SOD BICARB 50MEQ,5017194,CDM,250,RC,,,Outpatient,,,71.00,71.00,,41.71,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.71,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.37,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,63.9,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,63.9,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,33.37,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,63.9,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,41.71,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.37,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,33.37,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.37,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,33.37,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,33.37,63.9,
SOD CHLOR .9% 30 ML,5017200,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,24.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,24.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
SOD CHLOR INJ 1ML,5017204,CDM,250,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,23.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,23.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,23.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
SOD CHLOR 4MEQ/ML,5017207,CDM,250,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,18.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,18.048,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,18.048,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,18.048,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
SOD CHLORIDE FLSH EA,5017210,CDM,250,RC,,,Outpatient,,,21.00,21.00,,12.34,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.34,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.17,48.41,,161.112,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.9,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,18.9,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,47,,156.416,Percent of Total Billed Charges,47% of Total Billed Charges,18.9,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,12.34,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.87,47,,156.416,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.87,47,,156.416,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.87,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,18.9,
THIAMINE 100MG INJ,5017231,CDM,250,RC,,,Outpatient,,,44.00,44.00,,25.85,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.85,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.3,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,20.68,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,25.85,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,20.68,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,20.68,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,20.68,39.6,
TORADOL 15MG INJ,5017240,CDM,250,RC,,,Outpatient,,,33.00,33.00,,19.39,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.39,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.98,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,29.7,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,29.7,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,15.51,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,29.7,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,19.39,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.51,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,29.7,
HUMULIN NPH INJ,5017267,CDM,250,RC,,,Outpatient,,,27.50,27.50,,16.16,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.16,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.31,48.41,,8.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,24.75,90,,19.8,Percent of Total Billed Charges,90% of Total Billed Charges,24.75,90,,19.8,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,24.75,90,,19.8,Percent of Total Billed Charges,90% of Total Billed Charges,16.16,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.93,47,,7.896,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.93,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.93,47,,10.344,Percent of Total Billed Charges,47% of Total Billed Charges,12.93,47,,10.344,Percent of Total Billed Charges,47% of Total Billed Charges,12.93,24.75,
HUMULIN REG INJ,5017268,CDM,250,RC,,,Outpatient,,,67.00,67.00,,39.36,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.36,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.43,48.41,,18.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,60.3,90,,48.24,Percent of Total Billed Charges,90% of Total Billed Charges,60.3,90,,48.24,Percent of Total Billed Charges,90% of Total Billed Charges,31.49,47,,18.048,Percent of Total Billed Charges,47% of Total Billed Charges,60.3,90,,48.24,Percent of Total Billed Charges,90% of Total Billed Charges,39.36,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.49,47,,18.048,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.49,47,,18.048,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.49,47,,25.192,Percent of Total Billed Charges,47% of Total Billed Charges,31.49,47,,25.192,Percent of Total Billed Charges,47% of Total Billed Charges,31.49,60.3,
ADENOCARD 6MG INJ,5018007,CDM,250,RC,,,Outpatient,,,140.00,140.00,,82.25,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,82.25,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,67.77,48.41,,48.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,126,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,126,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,65.8,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,126,90,,100.8,Percent of Total Billed Charges,90% of Total Billed Charges,82.25,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,65.8,47,,47,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,65.8,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,65.8,47,,52.64,Percent of Total Billed Charges,47% of Total Billed Charges,65.8,47,,52.64,Percent of Total Billed Charges,47% of Total Billed Charges,65.8,126,
HEPARIN 10000 UNITS,5018014,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,216.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,216.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,14.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,216.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,13.912,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
PROCARDIA XL60,5018015,CDM,259,RC,,,Outpatient,,,15.40,15.40,,9.05,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.05,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.46,48.41,,15.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.86,90,,11.088,Percent of Total Billed Charges,90% of Total Billed Charges,13.86,90,,11.088,Percent of Total Billed Charges,90% of Total Billed Charges,7.24,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,13.86,90,,11.088,Percent of Total Billed Charges,90% of Total Billed Charges,9.05,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.24,47,,15.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.24,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.24,47,,5.792,Percent of Total Billed Charges,47% of Total Billed Charges,7.24,47,,5.792,Percent of Total Billed Charges,47% of Total Billed Charges,7.24,13.86,
HEPARIN 1000 UNITS H,5018016,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,8.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.896,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
HEPARIN 1000/ML10ML,5018019,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,72.168,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,70.064,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,70.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,70.064,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
HEPARIN 5000 UNITS H,5018026,CDM,250,RC,,,Outpatient,,,26.00,26.00,,15.28,58.75,,26.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.28,58.75,,26.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.59,48.41,,17.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,23.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,23.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,12.22,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,23.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,15.28,58.75,,26.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.22,47,,17.296,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.22,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.22,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,12.22,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,12.22,23.4,
HEPARIN LOCK 100UN,5018032,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,136.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,132.824,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,132.824,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,132.824,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
HEPARIN LOCK 10,5018033,CDM,250,RC,,,Outpatient,,,20.90,20.90,,12.28,58.75,,6.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.28,58.75,,6.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.12,48.41,,49.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,9.82,47,,47.752,Percent of Total Billed Charges,47% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,12.28,58.75,,6.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,47.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.82,47,,47.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,18.81,
AQUAMEPHYTON 10MG/CC,5018038,CDM,250,RC,,,Outpatient,,,212.00,212.00,,124.55,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,124.55,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,102.63,48.41,,61.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,190.8,90,,152.64,Percent of Total Billed Charges,90% of Total Billed Charges,190.8,90,,152.64,Percent of Total Billed Charges,90% of Total Billed Charges,99.64,47,,60.16,Percent of Total Billed Charges,47% of Total Billed Charges,190.8,90,,152.64,Percent of Total Billed Charges,90% of Total Billed Charges,124.55,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,99.64,47,,60.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,99.64,47,,60.16,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,99.64,47,,79.712,Percent of Total Billed Charges,47% of Total Billed Charges,99.64,47,,79.712,Percent of Total Billed Charges,47% of Total Billed Charges,99.64,190.8,
AQUAMEPHYTON 1MG/INF,5018041,CDM,250,RC,,,Outpatient,,,28.00,28.00,,16.45,58.75,,880.312,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,880.312,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,9.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,58.75,,880.312,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,9.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,25.2,
PROTAMINE 250MGVIAL,5018043,CDM,250,RC,,,Outpatient,,,86.00,86.00,,50.53,58.75,,871.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.53,58.75,,871.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.63,48.41,,61.576,Percent of Total Billed Charges,48.41% of Total Billed Charges,77.4,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,40.42,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,77.4,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,50.53,58.75,,871.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.42,47,,59.784,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.42,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.42,47,,32.336,Percent of Total Billed Charges,47% of Total Billed Charges,40.42,47,,32.336,Percent of Total Billed Charges,47% of Total Billed Charges,40.42,77.4,
ATROVENT INHALER,5019008,CDM,259,RC,,,Outpatient,,,298.00,298.00,,175.08,58.75,,86.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,175.08,58.75,,86.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,144.26,48.41,,44.928,Percent of Total Billed Charges,48.41% of Total Billed Charges,268.2,90,,214.56,Percent of Total Billed Charges,90% of Total Billed Charges,268.2,90,,214.56,Percent of Total Billed Charges,90% of Total Billed Charges,140.06,47,,43.616,Percent of Total Billed Charges,47% of Total Billed Charges,268.2,90,,214.56,Percent of Total Billed Charges,90% of Total Billed Charges,175.08,58.75,,86.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,140.06,47,,43.616,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,140.06,47,,43.616,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,140.06,47,,112.048,Percent of Total Billed Charges,47% of Total Billed Charges,140.06,47,,112.048,Percent of Total Billed Charges,47% of Total Billed Charges,140.06,268.2,
ATROPINE .4MG INJ H,5019009,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
SILVADENE CR 50GMJAR,5019031,CDM,270,RC,,,Outpatient,,,30.00,30.00,,17.63,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.63,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.52,48.41,,3169.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,27,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,27,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,47,,3076.768,Percent of Total Billed Charges,47% of Total Billed Charges,27,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,17.63,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,3076.768,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.1,47,,3076.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,27,
HYDRALAZINE 25MG TAB,5019049,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,6.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,6.208,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,6.208,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,6.208,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
HYDROXYZINE INJ,5019051,CDM,250,RC,,,Outpatient,,,80.00,80.00,,47,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,47,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.73,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,72,90,,57.6,Percent of Total Billed Charges,90% of Total Billed Charges,72,90,,57.6,Percent of Total Billed Charges,90% of Total Billed Charges,37.6,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,72,90,,57.6,Percent of Total Billed Charges,90% of Total Billed Charges,47,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.6,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,37.6,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.6,47,,30.08,Percent of Total Billed Charges,47% of Total Billed Charges,37.6,47,,30.08,Percent of Total Billed Charges,47% of Total Billed Charges,37.6,72,
BENADRYL 50MG INJ,5019058,CDM,250,RC,,,Outpatient,,,20.90,20.90,,12.28,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.28,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.12,48.41,,189.768,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,9.82,47,,184.24,Percent of Total Billed Charges,47% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,12.28,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,184.24,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.82,47,,184.24,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,18.81,
HISTOPLAS SKIN TEST,5019064,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,17.04,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,16.544,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
INDERIDE 160/50,5019069,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,41.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,40.12,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,40.12,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,40.12,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CLARITEN 10MG TAB,5019073,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
MOTRIN LIQ TSP,5019105,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,870.216,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,844.872,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,844.872,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,844.872,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
NARCAN .4MG H,5019108,CDM,250,RC,,,Outpatient,,,20.90,20.90,,12.28,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.28,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.12,48.41,,91.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,9.82,47,,89.112,Percent of Total Billed Charges,47% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,12.28,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,89.112,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.82,47,,89.112,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,18.81,
NARCAN NN .02MG/ML,5019110,CDM,250,RC,,,Outpatient,,,49.50,49.50,,29.08,58.75,,201.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.08,58.75,,201.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.96,48.41,,49.96,Percent of Total Billed Charges,48.41% of Total Billed Charges,44.55,90,,35.64,Percent of Total Billed Charges,90% of Total Billed Charges,44.55,90,,35.64,Percent of Total Billed Charges,90% of Total Billed Charges,23.27,47,,48.504,Percent of Total Billed Charges,47% of Total Billed Charges,44.55,90,,35.64,Percent of Total Billed Charges,90% of Total Billed Charges,29.08,58.75,,201.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.27,47,,48.504,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.27,47,,48.504,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.27,47,,18.616,Percent of Total Billed Charges,47% of Total Billed Charges,23.27,47,,18.616,Percent of Total Billed Charges,47% of Total Billed Charges,23.27,44.55,
PROVENTIL SYRUPTSP,5019112,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,36.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,36.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,36.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PROSTIGMIN 1:4000 1M,5019116,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
PROSTIGMIN 1MG 1ML,5019117,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
NEO-SYNEPHRINE 1ML,5019118,CDM,259,RC,,,Outpatient,,,33.00,33.00,,19.39,58.75,,11.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.39,58.75,,11.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.98,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,29.7,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,29.7,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,15.51,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,29.7,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,19.39,58.75,,11.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.51,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,29.7,
"POLYSPORIN POWD, 10G",5019121,CDM,259,RC,,,Outpatient,,,47.00,47.00,,27.61,58.75,,121.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.61,58.75,,121.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.75,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,22.09,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,27.61,58.75,,121.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,22.09,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,42.3,
PHENERGAN AMP 25MG,5019123,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,16.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,15.792,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
PHENERGAN AMP 50MG H,5019124,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
RHO-D IMMUNE GLOB,5019129,CDM,250,RC,,,Outpatient,,,461.00,461.00,,270.84,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,270.84,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,223.17,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,414.9,90,,331.92,Percent of Total Billed Charges,90% of Total Billed Charges,414.9,90,,331.92,Percent of Total Billed Charges,90% of Total Billed Charges,216.67,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,414.9,90,,331.92,Percent of Total Billed Charges,90% of Total Billed Charges,270.84,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,216.67,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,216.67,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,216.67,47,,173.336,Percent of Total Billed Charges,47% of Total Billed Charges,216.67,47,,173.336,Percent of Total Billed Charges,47% of Total Billed Charges,216.67,414.9,
ROBINUL H .3MG-.4MG,5019130,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,19.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,19.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,19.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
SLOW-MAG TAB,5019132,CDM,259,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,5.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,5.456,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
STER WATER 10 ML I,5019148,CDM,250,RC,,,Outpatient,,,21.00,21.00,,12.34,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.34,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.17,48.41,,11.232,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.9,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,18.9,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,18.9,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,12.34,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.87,47,,10.904,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.87,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.87,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,18.9,
MANNITOL 50ML H,5019150,CDM,250,RC,,,Outpatient,,,56.00,56.00,,32.9,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.9,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.11,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,50.4,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,50.4,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,26.32,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,50.4,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,32.9,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.32,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.32,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.32,47,,21.056,Percent of Total Billed Charges,47% of Total Billed Charges,26.32,47,,21.056,Percent of Total Billed Charges,47% of Total Billed Charges,26.32,50.4,
OSMOLITE 8OZ,5019175,CDM,259,RC,,,Outpatient,,,12.00,12.00,,7.05,58.75,,22.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,22.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,22.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
GLUCERNA 8OZ,5019176,CDM,270,RC,,,Outpatient,,,13.20,13.20,,7.76,58.75,,195.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.76,58.75,,195.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.39,48.41,,13.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.88,90,,9.504,Percent of Total Billed Charges,90% of Total Billed Charges,11.88,90,,9.504,Percent of Total Billed Charges,90% of Total Billed Charges,6.2,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,11.88,90,,9.504,Percent of Total Billed Charges,90% of Total Billed Charges,7.76,58.75,,195.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.2,47,,13.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.2,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.2,47,,4.96,Percent of Total Billed Charges,47% of Total Billed Charges,6.2,47,,4.96,Percent of Total Billed Charges,47% of Total Billed Charges,6.2,11.88,
JEVITY 8OZ,5019177,CDM,259,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
NEUPOGEN 480MCG,5019179,CDM,250,RC,,,Outpatient,,,1873.00,1873.00,,1100.39,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,1100.39,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,906.72,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,1685.7,90,,1348.56,Percent of Total Billed Charges,90% of Total Billed Charges,1685.7,90,,1348.56,Percent of Total Billed Charges,90% of Total Billed Charges,880.31,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,1685.7,90,,1348.56,Percent of Total Billed Charges,90% of Total Billed Charges,1100.39,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,880.31,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,880.31,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,880.31,47,,704.248,Percent of Total Billed Charges,47% of Total Billed Charges,880.31,47,,704.248,Percent of Total Billed Charges,47% of Total Billed Charges,880.31,1685.7,
EPOGEN 20000 UNITS/PROCRIT,5019180,CDM,250,RC,,,Outpatient,,,1854.00,1854.00,,1089.23,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,1089.23,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,897.52,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,1668.6,90,,1334.88,Percent of Total Billed Charges,90% of Total Billed Charges,1668.6,90,,1334.88,Percent of Total Billed Charges,90% of Total Billed Charges,871.38,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,1668.6,90,,1334.88,Percent of Total Billed Charges,90% of Total Billed Charges,1089.23,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,871.38,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,871.38,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,871.38,47,,697.104,Percent of Total Billed Charges,47% of Total Billed Charges,871.38,47,,697.104,Percent of Total Billed Charges,47% of Total Billed Charges,871.38,1668.6,
EPOGEN 3000 UNITS/PROCRIT,5019181,CDM,250,RC,,,Outpatient,,,185.00,185.00,,108.69,58.75,,22.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,108.69,58.75,,22.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.56,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,166.5,90,,133.2,Percent of Total Billed Charges,90% of Total Billed Charges,166.5,90,,133.2,Percent of Total Billed Charges,90% of Total Billed Charges,86.95,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,166.5,90,,133.2,Percent of Total Billed Charges,90% of Total Billed Charges,108.69,58.75,,22.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,86.95,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,86.95,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,86.95,47,,69.56,Percent of Total Billed Charges,47% of Total Billed Charges,86.95,47,,69.56,Percent of Total Billed Charges,47% of Total Billed Charges,86.95,166.5,
HELODEC DOSE,5019183,CDM,250,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,58.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,58.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,58.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
ATACAND 16MG,5019184,CDM,250,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,6.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,6.016,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
OXYCONTIN 10MG,5019189,CDM,250,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,5.536,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,5.376,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,5.376,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,5.376,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
CARDARONE 100/200 MG,5019190,CDM,250,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
ATENOLOL 50MG,5019191,CDM,250,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,87.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,87.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,87.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
COUMADIN 1MG,5019192,CDM,250,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,21.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,21.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,19.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,21.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,19.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
NORVASE 10MG,5019193,CDM,250,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,166.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,166.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,130.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,126.336,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,166.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,126.336,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,126.336,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
PACERONE 100/200 MG,5019194,CDM,250,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,59.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
CELEXA 20MG,5019195,CDM,250,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,75.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,75.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,48.024,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,46.624,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,75.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,46.624,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,46.624,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
CEFAZOLIN 1GM INJ,5019196,CDM,250,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,130.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,127.088,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,127.088,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,127.088,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
ROMAZICON 0.5 MG INJ,5019199,CDM,250,RC,,,Outpatient,,,428.00,428.00,,251.45,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,251.45,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,207.19,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,385.2,90,,308.16,Percent of Total Billed Charges,90% of Total Billed Charges,385.2,90,,308.16,Percent of Total Billed Charges,90% of Total Billed Charges,201.16,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,385.2,90,,308.16,Percent of Total Billed Charges,90% of Total Billed Charges,251.45,58.75,,74.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,201.16,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,201.16,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,201.16,47,,160.928,Percent of Total Billed Charges,47% of Total Billed Charges,201.16,47,,160.928,Percent of Total Billed Charges,47% of Total Billed Charges,201.16,385.2,
LIDOCAINE DRIP,5019200,CDM,250,RC,,,Outpatient,,,77.00,77.00,,45.24,58.75,,54.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.24,58.75,,54.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.28,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,69.3,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,69.3,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,36.19,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,69.3,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,45.24,58.75,,54.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,36.19,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,36.19,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,36.19,47,,28.952,Percent of Total Billed Charges,47% of Total Billed Charges,36.19,47,,28.952,Percent of Total Billed Charges,47% of Total Billed Charges,36.19,69.3,
COREG 25 MG TAB,5019201,CDM,250,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,212.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,206.424,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,206.424,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,206.424,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
COREG 6.25MG TAB,5019202,CDM,250,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,3845.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,3845.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,40.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,38.88,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,3845.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,38.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,38.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
ZOCOR 20MG TAB,5019203,CDM,250,RC,,,Outpatient,,,24.20,24.20,,14.22,58.75,,7.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.22,58.75,,7.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.72,48.41,,59.256,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.78,90,,17.424,Percent of Total Billed Charges,90% of Total Billed Charges,21.78,90,,17.424,Percent of Total Billed Charges,90% of Total Billed Charges,11.37,47,,57.528,Percent of Total Billed Charges,47% of Total Billed Charges,21.78,90,,17.424,Percent of Total Billed Charges,90% of Total Billed Charges,14.22,58.75,,7.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.37,47,,57.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.37,47,,57.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.37,47,,9.096,Percent of Total Billed Charges,47% of Total Billed Charges,11.37,47,,9.096,Percent of Total Billed Charges,47% of Total Billed Charges,11.37,21.78,
XALATAN OPH DROPS,5019206,CDM,250,RC,,,Outpatient,,,258.00,258.00,,151.58,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,151.58,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,124.9,48.41,,106.504,Percent of Total Billed Charges,48.41% of Total Billed Charges,232.2,90,,185.76,Percent of Total Billed Charges,90% of Total Billed Charges,232.2,90,,185.76,Percent of Total Billed Charges,90% of Total Billed Charges,121.26,47,,103.4,Percent of Total Billed Charges,47% of Total Billed Charges,232.2,90,,185.76,Percent of Total Billed Charges,90% of Total Billed Charges,151.58,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,121.26,47,,103.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,121.26,47,,103.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,121.26,47,,97.008,Percent of Total Billed Charges,47% of Total Billed Charges,121.26,47,,97.008,Percent of Total Billed Charges,47% of Total Billed Charges,121.26,232.2,
HEPARIN 25000 UNITS,5019207,CDM,250,RC,,,Outpatient,,,32.00,32.00,,18.8,58.75,,230.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,230.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,106.504,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,15.04,47,,103.4,Percent of Total Billed Charges,47% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,58.75,,230.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,103.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,103.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,28.8,
ERYTHROMYCIN 500MG T,5019209,CDM,250,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,161.112,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,156.416,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,156.416,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,156.416,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
HEPARIN FLUSH 5ML,5019210,CDM,250,RC,,,Outpatient,,,20.90,20.90,,12.28,58.75,,50.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.28,58.75,,50.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.12,48.41,,145.232,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,9.82,47,,141,Percent of Total Billed Charges,47% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,12.28,58.75,,50.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,141,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.82,47,,141,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,18.81,
KETAMINE 100MG 5ML,5019214,CDM,250,RC,,,Outpatient,,,42.00,42.00,,24.68,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.68,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.33,48.41,,181.632,Percent of Total Billed Charges,48.41% of Total Billed Charges,37.8,90,,30.24,Percent of Total Billed Charges,90% of Total Billed Charges,37.8,90,,30.24,Percent of Total Billed Charges,90% of Total Billed Charges,19.74,47,,176.344,Percent of Total Billed Charges,47% of Total Billed Charges,37.8,90,,30.24,Percent of Total Billed Charges,90% of Total Billed Charges,24.68,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.74,47,,176.344,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,19.74,47,,176.344,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.74,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,19.74,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,19.74,37.8,
ENLON-PLUS 10MGAMP,5019215,CDM,250,RC,,,Outpatient,,,28.00,28.00,,16.45,58.75,,1056.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,1056.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,54.992,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,47,,53.392,Percent of Total Billed Charges,47% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,58.75,,1056.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,53.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,53.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,25.2,
NALOXONE 0.4MG INJ,5019216,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,111.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,111.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,111.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
MORPHINE PCA INJ,5019222,CDM,250,RC,,,Outpatient,,,64.00,64.00,,37.6,58.75,,60.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.6,58.75,,60.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.98,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,57.6,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,57.6,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,30.08,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,57.6,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,37.6,58.75,,60.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.08,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,30.08,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.08,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,30.08,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,30.08,57.6,
CELEBREX 200MG CAP,5019224,CDM,250,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
TEARS ARTIF OS 15ML,5019229,CDM,250,RC,,,Outpatient,,,48.00,48.00,,28.2,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.2,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.24,48.41,,105.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,43.2,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,43.2,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,22.56,47,,102.576,Percent of Total Billed Charges,47% of Total Billed Charges,43.2,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,28.2,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.56,47,,102.576,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,22.56,47,,102.576,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.56,47,,18.048,Percent of Total Billed Charges,47% of Total Billed Charges,22.56,47,,18.048,Percent of Total Billed Charges,47% of Total Billed Charges,22.56,43.2,
CATAPRES TTS 3,5019230,CDM,250,RC,,,Outpatient,,,416.00,416.00,,244.4,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,244.4,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,201.39,48.41,,22.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,374.4,90,,299.52,Percent of Total Billed Charges,90% of Total Billed Charges,374.4,90,,299.52,Percent of Total Billed Charges,90% of Total Billed Charges,195.52,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,374.4,90,,299.52,Percent of Total Billed Charges,90% of Total Billed Charges,244.4,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,195.52,47,,21.432,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,195.52,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,195.52,47,,156.416,Percent of Total Billed Charges,47% of Total Billed Charges,195.52,47,,156.416,Percent of Total Billed Charges,47% of Total Billed Charges,195.52,374.4,
HYZAAR 100MG/25TAB,5019231,CDM,250,RC,,,Outpatient,,,12.00,12.00,,7.05,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,22.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,21.432,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
PREVACID 15MG,5019233,CDM,250,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
LANTISEPTIC OINT 130,5019234,CDM,250,RC,,,Outpatient,,,21.00,21.00,,12.34,58.75,,19.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.34,58.75,,19.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.17,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.9,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,18.9,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,18.9,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,12.34,58.75,,19.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.87,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.87,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.87,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,18.9,
ZYPREXIA 10MG,5019235,CDM,250,RC,,,Outpatient,,,48.00,48.00,,28.2,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.2,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.24,48.41,,73.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,43.2,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,43.2,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,22.56,47,,71.44,Percent of Total Billed Charges,47% of Total Billed Charges,43.2,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,28.2,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.56,47,,71.44,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,22.56,47,,71.44,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.56,47,,18.048,Percent of Total Billed Charges,47% of Total Billed Charges,22.56,47,,18.048,Percent of Total Billed Charges,47% of Total Billed Charges,22.56,43.2,
EPOGEN 2000 UNITS/PROCRIT,5019236,CDM,250,RC,,,Outpatient,,,125.00,125.00,,73.44,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.44,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,60.51,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,112.5,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,112.5,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,58.75,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,112.5,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,73.44,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,58.75,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,58.75,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,58.75,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,58.75,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,58.75,112.5,
LIDOCAINE JELLY2%,5019237,CDM,250,RC,,,Outpatient,,,37.00,37.00,,21.74,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.74,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.91,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,33.3,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,33.3,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,17.39,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,33.3,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,21.74,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.39,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.39,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.39,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,17.39,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,17.39,33.3,
ACTOS 30MG TAB,5019238,CDM,250,RC,,,Outpatient,,,40.00,40.00,,23.5,58.75,,6.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.5,58.75,,6.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.36,48.41,,3.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,23.5,58.75,,6.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,3.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.8,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,36,
ACTOS 15MG,5019239,CDM,250,RC,,,Outpatient,,,21.00,21.00,,12.34,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.34,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.17,48.41,,76.296,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.9,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,18.9,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,47,,74.072,Percent of Total Billed Charges,47% of Total Billed Charges,18.9,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,12.34,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.87,47,,74.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.87,47,,74.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.87,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,18.9,
ZITHROMAX 200MGSUSP,5019240,CDM,250,RC,,,Outpatient,,,186.35,186.35,,109.48,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,109.48,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,90.21,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,167.72,90,,134.176,Percent of Total Billed Charges,90% of Total Billed Charges,167.72,90,,134.176,Percent of Total Billed Charges,90% of Total Billed Charges,87.58,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,167.72,90,,134.176,Percent of Total Billed Charges,90% of Total Billed Charges,109.48,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,87.58,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,87.58,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,87.58,47,,70.064,Percent of Total Billed Charges,47% of Total Billed Charges,87.58,47,,70.064,Percent of Total Billed Charges,47% of Total Billed Charges,87.58,167.72,
DOBUTAMINE 250 MG,5019241,CDM,250,RC,,,Outpatient,,,46.00,46.00,,27.03,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.03,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.27,48.41,,10.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,41.4,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,41.4,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,21.62,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,41.4,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,27.03,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.62,47,,9.776,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,21.62,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.62,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,21.62,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,21.62,41.4,
ROCEPHIN 2GM,5019242,CDM,250,RC,,,Outpatient,,,353.25,353.25,,207.53,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,207.53,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,171.01,48.41,,211.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,317.93,90,,254.344,Percent of Total Billed Charges,90% of Total Billed Charges,317.93,90,,254.344,Percent of Total Billed Charges,90% of Total Billed Charges,166.03,47,,205.296,Percent of Total Billed Charges,47% of Total Billed Charges,317.93,90,,254.344,Percent of Total Billed Charges,90% of Total Billed Charges,207.53,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,166.03,47,,205.296,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,166.03,47,,205.296,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,166.03,47,,132.824,Percent of Total Billed Charges,47% of Total Billed Charges,166.03,47,,132.824,Percent of Total Billed Charges,47% of Total Billed Charges,166.03,317.93,
FRAGMIN 5000 UNITS,5019243,CDM,250,RC,,,Outpatient,,,127.00,127.00,,74.61,58.75,,16.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.61,58.75,,16.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.48,48.41,,135.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,114.3,90,,91.44,Percent of Total Billed Charges,90% of Total Billed Charges,114.3,90,,91.44,Percent of Total Billed Charges,90% of Total Billed Charges,59.69,47,,131.6,Percent of Total Billed Charges,47% of Total Billed Charges,114.3,90,,91.44,Percent of Total Billed Charges,90% of Total Billed Charges,74.61,58.75,,16.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,59.69,47,,131.6,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,59.69,47,,131.6,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,59.69,47,,47.752,Percent of Total Billed Charges,47% of Total Billed Charges,59.69,47,,47.752,Percent of Total Billed Charges,47% of Total Billed Charges,59.69,114.3,
PRIMAXIN 500MG IV,5019244,CDM,250,RC,,,Outpatient,,,160.00,160.00,,94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,77.46,48.41,,98.368,Percent of Total Billed Charges,48.41% of Total Billed Charges,144,90,,115.2,Percent of Total Billed Charges,90% of Total Billed Charges,144,90,,115.2,Percent of Total Billed Charges,90% of Total Billed Charges,75.2,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,144,90,,115.2,Percent of Total Billed Charges,90% of Total Billed Charges,94,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,75.2,47,,95.504,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,75.2,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,75.2,47,,60.16,Percent of Total Billed Charges,47% of Total Billed Charges,75.2,47,,60.16,Percent of Total Billed Charges,47% of Total Billed Charges,75.2,144,
PROTONIX 40MG O,5019245,CDM,250,RC,,,Outpatient,,,25.00,25.00,,14.69,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.69,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.1,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,14.69,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.75,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,22.5,
VENTOLIN,5019246,CDM,250,RC,,,Outpatient,,,159.00,159.00,,93.41,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,93.41,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,76.97,48.41,,6.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,143.1,90,,114.48,Percent of Total Billed Charges,90% of Total Billed Charges,143.1,90,,114.48,Percent of Total Billed Charges,90% of Total Billed Charges,74.73,47,,5.92,Percent of Total Billed Charges,47% of Total Billed Charges,143.1,90,,114.48,Percent of Total Billed Charges,90% of Total Billed Charges,93.41,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,74.73,47,,5.92,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,74.73,47,,5.92,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,74.73,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,74.73,47,,59.784,Percent of Total Billed Charges,47% of Total Billed Charges,74.73,143.1,
PREVACID IV,5019247,CDM,250,RC,,,Outpatient,,,116.00,116.00,,68.15,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,68.15,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,56.16,48.41,,53.448,Percent of Total Billed Charges,48.41% of Total Billed Charges,104.4,90,,83.52,Percent of Total Billed Charges,90% of Total Billed Charges,104.4,90,,83.52,Percent of Total Billed Charges,90% of Total Billed Charges,54.52,47,,51.888,Percent of Total Billed Charges,47% of Total Billed Charges,104.4,90,,83.52,Percent of Total Billed Charges,90% of Total Billed Charges,68.15,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,54.52,47,,51.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,54.52,47,,51.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,54.52,47,,43.616,Percent of Total Billed Charges,47% of Total Billed Charges,54.52,47,,43.616,Percent of Total Billed Charges,47% of Total Billed Charges,54.52,104.4,
GLUTOSE ORAL GLUCOSE,5019248,CDM,250,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,28.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,28.128,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,28.128,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,28.128,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
TNKASE,5019249,CDM,250,RC,92977,HCPCS,Outpatient,,,8182.90,8182.90,,4807.45,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,4807.45,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,3961.34,48.41,,9.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,339.36,100,,,fee Schedule,100% of ASC Tier Groupings ,339.36,100,,,Fee Schedule,100% of ASC Tier Groupings,3845.96,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,339.36,100,,,Fee Schedule,100% of ASC Tier Groupings,4807.45,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3845.96,47,,9.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3845.96,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,51.83,115,,,Fee Schedule,115% of CMS OPPS Rate,51.83,115,,,Fee Schedule,115% of CMS OPPS Rate,51.83,4807.45,
DETROL LA 4 MG,5019250,CDM,250,RC,,,Outpatient,,,16.50,16.50,,9.69,58.75,,6.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.69,58.75,,6.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.99,48.41,,57.704,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.85,90,,11.88,Percent of Total Billed Charges,90% of Total Billed Charges,14.85,90,,11.88,Percent of Total Billed Charges,90% of Total Billed Charges,7.76,47,,56.024,Percent of Total Billed Charges,47% of Total Billed Charges,14.85,90,,11.88,Percent of Total Billed Charges,90% of Total Billed Charges,9.69,58.75,,6.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.76,47,,56.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.76,47,,56.024,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.76,47,,6.208,Percent of Total Billed Charges,47% of Total Billed Charges,7.76,47,,6.208,Percent of Total Billed Charges,47% of Total Billed Charges,7.76,14.85,
ARGINAD,5019253,CDM,250,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,26.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,25.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
FLOVENT INHALER,5019254,CDM,250,RC,,,Outpatient,,,490.00,490.00,,287.88,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,287.88,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,237.21,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,441,90,,352.8,Percent of Total Billed Charges,90% of Total Billed Charges,441,90,,352.8,Percent of Total Billed Charges,90% of Total Billed Charges,230.3,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,441,90,,352.8,Percent of Total Billed Charges,90% of Total Billed Charges,287.88,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,230.3,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,230.3,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,230.3,47,,184.24,Percent of Total Billed Charges,47% of Total Billed Charges,230.3,47,,184.24,Percent of Total Billed Charges,47% of Total Billed Charges,230.3,441,
LEVAQUIN 250MG TAB,5019255,CDM,250,RC,,,Outpatient,,,44.00,44.00,,25.85,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.85,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.3,48.41,,36.792,Percent of Total Billed Charges,48.41% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,20.68,47,,35.72,Percent of Total Billed Charges,47% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,25.85,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,35.72,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,20.68,47,,35.72,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,20.68,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,20.68,39.6,
LEVAQUIN 250MG IV,5019256,CDM,250,RC,,,Outpatient,,,106.70,106.70,,62.69,58.75,,157.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.69,58.75,,157.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.65,48.41,,43.12,Percent of Total Billed Charges,48.41% of Total Billed Charges,96.03,90,,76.824,Percent of Total Billed Charges,90% of Total Billed Charges,96.03,90,,76.824,Percent of Total Billed Charges,90% of Total Billed Charges,50.15,47,,41.864,Percent of Total Billed Charges,47% of Total Billed Charges,96.03,90,,76.824,Percent of Total Billed Charges,90% of Total Billed Charges,62.69,58.75,,157.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,50.15,47,,41.864,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,50.15,47,,41.864,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,50.15,47,,40.12,Percent of Total Billed Charges,47% of Total Billed Charges,50.15,47,,40.12,Percent of Total Billed Charges,47% of Total Billed Charges,50.15,96.03,
CARDIZEM CD 300MG,5019260,CDM,250,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,17.896,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,17.368,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,17.368,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,17.368,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
EPOGEN 40000 UNITS/PROCRIT,5019261,CDM,250,RC,,,Outpatient,,,2247.00,2247.00,,1320.11,58.75,,58.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,1320.11,58.75,,58.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,1087.77,48.41,,116.304,Percent of Total Billed Charges,48.41% of Total Billed Charges,2022.3,90,,1617.84,Percent of Total Billed Charges,90% of Total Billed Charges,2022.3,90,,1617.84,Percent of Total Billed Charges,90% of Total Billed Charges,1056.09,47,,112.912,Percent of Total Billed Charges,47% of Total Billed Charges,2022.3,90,,1617.84,Percent of Total Billed Charges,90% of Total Billed Charges,1320.11,58.75,,58.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1056.09,47,,112.912,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1056.09,47,,112.912,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1056.09,47,,844.872,Percent of Total Billed Charges,47% of Total Billed Charges,1056.09,47,,844.872,Percent of Total Billed Charges,47% of Total Billed Charges,1056.09,2022.3,
NASAREL,5019262,CDM,250,RC,,,Outpatient,,,237.00,237.00,,139.24,58.75,,158.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,139.24,58.75,,158.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,114.73,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,213.3,90,,170.64,Percent of Total Billed Charges,90% of Total Billed Charges,213.3,90,,170.64,Percent of Total Billed Charges,90% of Total Billed Charges,111.39,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,213.3,90,,170.64,Percent of Total Billed Charges,90% of Total Billed Charges,139.24,58.75,,158.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,111.39,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,111.39,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,111.39,47,,89.112,Percent of Total Billed Charges,47% of Total Billed Charges,111.39,47,,89.112,Percent of Total Billed Charges,47% of Total Billed Charges,111.39,213.3,
ZITHROMAX 250MGIV,5019263,CDM,250,RC,,,Outpatient,,,129.00,129.00,,75.79,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.79,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.45,48.41,,3.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,116.1,90,,92.88,Percent of Total Billed Charges,90% of Total Billed Charges,116.1,90,,92.88,Percent of Total Billed Charges,90% of Total Billed Charges,60.63,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,116.1,90,,92.88,Percent of Total Billed Charges,90% of Total Billed Charges,75.79,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,60.63,47,,3.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,60.63,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,60.63,47,,48.504,Percent of Total Billed Charges,47% of Total Billed Charges,60.63,47,,48.504,Percent of Total Billed Charges,47% of Total Billed Charges,60.63,116.1,
IMDUR 15 MG,5019264,CDM,250,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,13.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,13.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DEPAKOTE 500,5019265,CDM,250,RC,,,Outpatient,,,12.00,12.00,,7.05,58.75,,258.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,258.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,8.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,258.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,8.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
MEGACE 100MG,5019266,CDM,250,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,48.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,48.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,5.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,5.168,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,48.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,5.168,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,5.168,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
SOLU-MEDROL 80MG,5019267,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,71.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,71.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,1883.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,1828.488,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,71.912,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,1828.488,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,1828.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
PEPTO BISMOL TAB/TBS,5019268,CDM,250,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,129.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,129.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1491.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1447.6,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,129.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1447.6,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1447.6,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PHENERGAN VC 4OZ,5019271,CDM,250,RC,,,Outpatient,,,42.00,42.00,,24.68,58.75,,129.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.68,58.75,,129.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.33,48.41,,112.696,Percent of Total Billed Charges,48.41% of Total Billed Charges,37.8,90,,30.24,Percent of Total Billed Charges,90% of Total Billed Charges,37.8,90,,30.24,Percent of Total Billed Charges,90% of Total Billed Charges,19.74,47,,109.416,Percent of Total Billed Charges,47% of Total Billed Charges,37.8,90,,30.24,Percent of Total Billed Charges,90% of Total Billed Charges,24.68,58.75,,129.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.74,47,,109.416,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,19.74,47,,109.416,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.74,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,19.74,47,,15.792,Percent of Total Billed Charges,47% of Total Billed Charges,19.74,37.8,
PHENERGAN DM-4OZ,5019272,CDM,250,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,195.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,195.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,96.432,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,93.624,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,195.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,93.624,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,93.624,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
MOTRIN 200 MG PO,5019273,CDM,250,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,176.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,176.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,144.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,139.872,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,176.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,139.872,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,139.872,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
GLUCOVANCE ALL STR,5019275,CDM,250,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,220.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,220.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,14.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,220.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,13.912,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
NICOTINE 21MG PATCH,5019276,CDM,250,RC,,,Outpatient,,,14.50,14.50,,8.52,58.75,,66.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.52,58.75,,66.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.02,48.41,,14.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.05,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,13.05,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,6.82,47,,14.104,Percent of Total Billed Charges,47% of Total Billed Charges,13.05,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,8.52,58.75,,66.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.82,47,,14.104,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.82,47,,14.104,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.82,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,6.82,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,6.82,13.05,
ACTOS 45MG,5019277,CDM,250,RC,,,Outpatient,,,29.00,29.00,,17.04,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.04,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.04,48.41,,1044.496,Percent of Total Billed Charges,48.41% of Total Billed Charges,26.1,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,26.1,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,13.63,47,,1014.072,Percent of Total Billed Charges,47% of Total Billed Charges,26.1,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,17.04,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.63,47,,1014.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.63,47,,1014.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.63,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,13.63,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,13.63,26.1,
ZESTRIL 20MG,5019278,CDM,250,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
PREDNISONE 1MG,5019279,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SEROQUEL 100 MGTAB,5019280,CDM,259,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,128.216,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,128.216,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,128.216,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
ARICEPT 10MG,5019281,CDM,259,RC,,,Outpatient,,,35.00,35.00,,20.56,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.56,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.94,48.41,,137.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,31.5,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,31.5,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,47,,133.856,Percent of Total Billed Charges,47% of Total Billed Charges,31.5,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,20.56,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.45,47,,133.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.45,47,,133.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.45,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,16.45,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,16.45,31.5,
SLELAXIN 800MG,5019283,CDM,259,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
GLUCOTROL XL 10MG,5019284,CDM,270,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,14.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,13.912,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
COUMADIN 4MG,5019285,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
PHENERGAN DM DOSE,5019286,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,89.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,89.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,89.304,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ZYRTEC SYRUP 5CC,5019287,CDM,250,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,31.528,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,30.608,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,30.608,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,30.608,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
LEXAPRO 10MG,5019288,CDM,250,RC,,,Outpatient,,,16.00,16.00,,9.4,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.4,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.75,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.4,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,14.4,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,7.52,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,14.4,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.52,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.52,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.52,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,7.52,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,7.52,14.4,
LEXAPRO 20 MG,5019289,CDM,250,RC,,,Outpatient,,,14.30,14.30,,8.4,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.4,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.92,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.87,90,,10.296,Percent of Total Billed Charges,90% of Total Billed Charges,12.87,90,,10.296,Percent of Total Billed Charges,90% of Total Billed Charges,6.72,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,12.87,90,,10.296,Percent of Total Billed Charges,90% of Total Billed Charges,8.4,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.72,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.72,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.72,47,,5.376,Percent of Total Billed Charges,47% of Total Billed Charges,6.72,47,,5.376,Percent of Total Billed Charges,47% of Total Billed Charges,6.72,12.87,
CRESTOR ALL STRENGTH,5019290,CDM,250,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,92.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,92.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,92.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
ROBITUSSIN AC 4OZ B,5019291,CDM,250,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,84.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,81.968,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,81.968,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,81.968,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
HUMALOG/NOVOLOG,5019292,CDM,250,RC,,,Outpatient,,,51.00,51.00,,29.96,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.96,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.69,48.41,,68.16,Percent of Total Billed Charges,48.41% of Total Billed Charges,45.9,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,45.9,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,23.97,47,,66.176,Percent of Total Billed Charges,47% of Total Billed Charges,45.9,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,29.96,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,66.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.97,47,,66.176,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,45.9,
AMIODARONE 150MG H,5019293,CDM,250,RC,,,Outpatient,,,336.00,336.00,,197.4,58.75,,256.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,197.4,58.75,,256.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,162.66,48.41,,8.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,302.4,90,,241.92,Percent of Total Billed Charges,90% of Total Billed Charges,302.4,90,,241.92,Percent of Total Billed Charges,90% of Total Billed Charges,157.92,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,302.4,90,,241.92,Percent of Total Billed Charges,90% of Total Billed Charges,197.4,58.75,,256.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,157.92,47,,7.896,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,157.92,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,157.92,47,,126.336,Percent of Total Billed Charges,47% of Total Billed Charges,157.92,47,,126.336,Percent of Total Billed Charges,47% of Total Billed Charges,157.92,302.4,
TYLENOL COD ELIZ 4OZ,5019294,CDM,259,RC,,,Outpatient,,,32.00,32.00,,18.8,58.75,,164.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,164.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,35.24,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,15.04,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,58.75,,164.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,34.216,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,28.8,
LEVAQUIN 750 MGTAB,5019295,CDM,250,RC,,,Outpatient,,,124.00,124.00,,72.85,58.75,,119.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,72.85,58.75,,119.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,60.03,48.41,,44.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,111.6,90,,89.28,Percent of Total Billed Charges,90% of Total Billed Charges,111.6,90,,89.28,Percent of Total Billed Charges,90% of Total Billed Charges,58.28,47,,42.864,Percent of Total Billed Charges,47% of Total Billed Charges,111.6,90,,89.28,Percent of Total Billed Charges,90% of Total Billed Charges,72.85,58.75,,119.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,58.28,47,,42.864,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,58.28,47,,42.864,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,58.28,47,,46.624,Percent of Total Billed Charges,47% of Total Billed Charges,58.28,47,,46.624,Percent of Total Billed Charges,47% of Total Billed Charges,58.28,111.6,
LEVAQUIN 750 IV,5019296,CDM,250,RC,,,Outpatient,,,338.00,338.00,,198.58,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,198.58,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,163.63,48.41,,35.24,Percent of Total Billed Charges,48.41% of Total Billed Charges,304.2,90,,243.36,Percent of Total Billed Charges,90% of Total Billed Charges,304.2,90,,243.36,Percent of Total Billed Charges,90% of Total Billed Charges,158.86,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,304.2,90,,243.36,Percent of Total Billed Charges,90% of Total Billed Charges,198.58,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,158.86,47,,34.216,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,158.86,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,158.86,47,,127.088,Percent of Total Billed Charges,47% of Total Billed Charges,158.86,47,,127.088,Percent of Total Billed Charges,47% of Total Billed Charges,158.86,304.2,
COZAAR 100 MG,5019297,CDM,259,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,7.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,7.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,35.24,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,7.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,34.216,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
TOPROL XL 25 MG,5019298,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,64.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,64.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,77.104,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,74.864,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,64.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,74.864,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,74.864,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
VASOPRESSIN,5019299,CDM,250,RC,,,Outpatient,,,549.00,549.00,,322.54,58.75,,35.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,322.54,58.75,,35.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,265.77,48.41,,1020.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,494.1,90,,395.28,Percent of Total Billed Charges,90% of Total Billed Charges,494.1,90,,395.28,Percent of Total Billed Charges,90% of Total Billed Charges,258.03,47,,991.136,Percent of Total Billed Charges,47% of Total Billed Charges,494.1,90,,395.28,Percent of Total Billed Charges,90% of Total Billed Charges,322.54,58.75,,35.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,258.03,47,,991.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,258.03,47,,991.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,258.03,47,,206.424,Percent of Total Billed Charges,47% of Total Billed Charges,258.03,47,,206.424,Percent of Total Billed Charges,47% of Total Billed Charges,258.03,494.1,
LOVENOX 30 MG INJ,5019300,CDM,250,RC,,,Outpatient,,,103.40,103.40,,60.75,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,60.75,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.06,48.41,,37.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,93.06,90,,74.448,Percent of Total Billed Charges,90% of Total Billed Charges,93.06,90,,74.448,Percent of Total Billed Charges,90% of Total Billed Charges,48.6,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,93.06,90,,74.448,Percent of Total Billed Charges,90% of Total Billed Charges,60.75,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.6,47,,36.848,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,48.6,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.6,47,,38.88,Percent of Total Billed Charges,47% of Total Billed Charges,48.6,47,,38.88,Percent of Total Billed Charges,47% of Total Billed Charges,48.6,93.06,
LOVENOX 40 MG INJ,5019301,CDM,250,RC,,,Outpatient,,,153.00,153.00,,89.89,58.75,,70.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.89,58.75,,70.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.07,48.41,,70.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,137.7,90,,110.16,Percent of Total Billed Charges,90% of Total Billed Charges,137.7,90,,110.16,Percent of Total Billed Charges,90% of Total Billed Charges,71.91,47,,68.056,Percent of Total Billed Charges,47% of Total Billed Charges,137.7,90,,110.16,Percent of Total Billed Charges,90% of Total Billed Charges,89.89,58.75,,70.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,71.91,47,,68.056,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,71.91,47,,68.056,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,71.91,47,,57.528,Percent of Total Billed Charges,47% of Total Billed Charges,71.91,47,,57.528,Percent of Total Billed Charges,47% of Total Billed Charges,71.91,137.7,
LOVENOX 60 MG INJ,5019302,CDM,250,RC,,,Outpatient,,,275.00,275.00,,161.56,58.75,,31.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,161.56,58.75,,31.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,133.13,48.41,,3.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,247.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,247.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,129.25,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,247.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,161.56,58.75,,31.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,129.25,47,,3.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,129.25,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,129.25,47,,103.4,Percent of Total Billed Charges,47% of Total Billed Charges,129.25,47,,103.4,Percent of Total Billed Charges,47% of Total Billed Charges,129.25,247.5,
LOVENOX 80 MG,5019303,CDM,250,RC,,,Outpatient,,,275.00,275.00,,161.56,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,161.56,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,133.13,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,247.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,247.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,129.25,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,247.5,90,,198,Percent of Total Billed Charges,90% of Total Billed Charges,161.56,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,129.25,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,129.25,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,129.25,47,,103.4,Percent of Total Billed Charges,47% of Total Billed Charges,129.25,47,,103.4,Percent of Total Billed Charges,47% of Total Billed Charges,129.25,247.5,
LOVENOX 100 MG INJ,5019304,CDM,250,RC,,,Outpatient,,,416.00,416.00,,244.4,58.75,,44.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,244.4,58.75,,44.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,201.39,48.41,,13.944,Percent of Total Billed Charges,48.41% of Total Billed Charges,374.4,90,,299.52,Percent of Total Billed Charges,90% of Total Billed Charges,374.4,90,,299.52,Percent of Total Billed Charges,90% of Total Billed Charges,195.52,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,374.4,90,,299.52,Percent of Total Billed Charges,90% of Total Billed Charges,244.4,58.75,,44.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,195.52,47,,13.536,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,195.52,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,195.52,47,,156.416,Percent of Total Billed Charges,47% of Total Billed Charges,195.52,47,,156.416,Percent of Total Billed Charges,47% of Total Billed Charges,195.52,374.4,
LOVENOX 120 MG,5019305,CDM,250,RC,,,Outpatient,,,375.00,375.00,,220.31,58.75,,52.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,220.31,58.75,,52.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,181.54,48.41,,9530.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,337.5,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,337.5,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,176.25,47,,9252.608,Percent of Total Billed Charges,47% of Total Billed Charges,337.5,90,,270,Percent of Total Billed Charges,90% of Total Billed Charges,220.31,58.75,,52.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,176.25,47,,9252.608,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,176.25,47,,9252.608,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,176.25,47,,141,Percent of Total Billed Charges,47% of Total Billed Charges,176.25,47,,141,Percent of Total Billed Charges,47% of Total Billed Charges,176.25,337.5,
LOVENOX 150 MG INJ,5019306,CDM,250,RC,,,Outpatient,,,469.00,469.00,,275.54,58.75,,21.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,275.54,58.75,,21.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,227.04,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,422.1,90,,337.68,Percent of Total Billed Charges,90% of Total Billed Charges,422.1,90,,337.68,Percent of Total Billed Charges,90% of Total Billed Charges,220.43,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,422.1,90,,337.68,Percent of Total Billed Charges,90% of Total Billed Charges,275.54,58.75,,21.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,220.43,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,220.43,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,220.43,47,,176.344,Percent of Total Billed Charges,47% of Total Billed Charges,220.43,47,,176.344,Percent of Total Billed Charges,47% of Total Billed Charges,220.43,422.1,
ZYRTEC 4OZ BOTTLE,5020151,CDM,250,RC,,,Outpatient,,,142.00,142.00,,83.43,58.75,,141.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,83.43,58.75,,141.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,68.74,48.41,,112.696,Percent of Total Billed Charges,48.41% of Total Billed Charges,127.8,90,,102.24,Percent of Total Billed Charges,90% of Total Billed Charges,127.8,90,,102.24,Percent of Total Billed Charges,90% of Total Billed Charges,66.74,47,,109.416,Percent of Total Billed Charges,47% of Total Billed Charges,127.8,90,,102.24,Percent of Total Billed Charges,90% of Total Billed Charges,83.43,58.75,,141.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,66.74,47,,109.416,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,66.74,47,,109.416,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,66.74,47,,53.392,Percent of Total Billed Charges,47% of Total Billed Charges,66.74,47,,53.392,Percent of Total Billed Charges,47% of Total Billed Charges,66.74,127.8,
GLUCOPHAGE 850MG,5020153,CDM,250,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
ACCUPRIL 20MG,5020154,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,25.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,24.816,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
HUMULIN 70/30 INSUL,5020155,CDM,250,RC,,,Outpatient,,,28.00,28.00,,16.45,58.75,,16.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,16.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,1736.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,47,,1686.36,Percent of Total Billed Charges,47% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,58.75,,16.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,1686.36,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,1686.36,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,25.2,
EPOGEN 4000 UNITS/PROCRIT,5020156,CDM,250,RC,,,Outpatient,,,272.80,272.80,,160.27,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,160.27,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,132.06,48.41,,29.432,Percent of Total Billed Charges,48.41% of Total Billed Charges,245.52,90,,196.416,Percent of Total Billed Charges,90% of Total Billed Charges,245.52,90,,196.416,Percent of Total Billed Charges,90% of Total Billed Charges,128.22,47,,28.576,Percent of Total Billed Charges,47% of Total Billed Charges,245.52,90,,196.416,Percent of Total Billed Charges,90% of Total Billed Charges,160.27,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,128.22,47,,28.576,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,128.22,47,,28.576,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,128.22,47,,102.576,Percent of Total Billed Charges,47% of Total Billed Charges,128.22,47,,102.576,Percent of Total Billed Charges,47% of Total Billed Charges,128.22,245.52,
LANTUS INSULIN DOSE,5020157,CDM,250,RC,,,Outpatient,,,57.00,57.00,,33.49,58.75,,6.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.49,58.75,,6.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.59,48.41,,33.304,Percent of Total Billed Charges,48.41% of Total Billed Charges,51.3,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,51.3,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,26.79,47,,32.336,Percent of Total Billed Charges,47% of Total Billed Charges,51.3,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,33.49,58.75,,6.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,32.336,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.79,47,,32.336,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,26.79,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,26.79,51.3,
HUMALOG MIX 75/25,5020158,CDM,250,RC,,,Outpatient,,,57.00,57.00,,33.49,58.75,,2285.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.49,58.75,,2285.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.59,48.41,,1450.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,51.3,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,51.3,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,26.79,47,,1408.12,Percent of Total Billed Charges,47% of Total Billed Charges,51.3,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,33.49,58.75,,2285.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,1408.12,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.79,47,,1408.12,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,26.79,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,26.79,51.3,
TYLENOL PM,5020160,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,1809.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,1809.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2059.944,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1999.944,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,1809.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1999.944,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1999.944,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SKELAXIN 400MG,5020161,CDM,250,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,136.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,136.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1977.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1920.232,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,136.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1920.232,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1920.232,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
HEP B VACCINE,5020162,CDM,250,RC,,,Outpatient,,,190.00,190.00,,111.63,58.75,,117.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,111.63,58.75,,117.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,91.98,48.41,,27.496,Percent of Total Billed Charges,48.41% of Total Billed Charges,171,90,,136.8,Percent of Total Billed Charges,90% of Total Billed Charges,171,90,,136.8,Percent of Total Billed Charges,90% of Total Billed Charges,89.3,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,171,90,,136.8,Percent of Total Billed Charges,90% of Total Billed Charges,111.63,58.75,,117.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,89.3,47,,26.696,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,89.3,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,89.3,47,,71.44,Percent of Total Billed Charges,47% of Total Billed Charges,89.3,47,,71.44,Percent of Total Billed Charges,47% of Total Billed Charges,89.3,171,
LIPITOR 20MG,5020164,CDM,250,RC,,,Outpatient,,,12.00,12.00,,7.05,58.75,,174.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,174.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,518.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,503.088,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,174.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,503.088,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,503.088,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
LIPITOR 40G,5020165,CDM,250,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,7.24,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,7.032,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,7.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,7.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
NEURONTIN 400MG,5020166,CDM,250,RC,,,Outpatient,,,9.00,9.00,,5.29,58.75,,17.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.29,58.75,,17.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.36,48.41,,7.976,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.1,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,47,,7.744,Percent of Total Billed Charges,47% of Total Billed Charges,8.1,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,58.75,,17.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,7.744,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.23,47,,7.744,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,8.1,
AUGMENTIN 400MG50ML,5020167,CDM,250,RC,,,Outpatient,,,197.00,197.00,,115.74,58.75,,1267.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,115.74,58.75,,1267.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,95.37,48.41,,45.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,177.3,90,,141.84,Percent of Total Billed Charges,90% of Total Billed Charges,177.3,90,,141.84,Percent of Total Billed Charges,90% of Total Billed Charges,92.59,47,,44.256,Percent of Total Billed Charges,47% of Total Billed Charges,177.3,90,,141.84,Percent of Total Billed Charges,90% of Total Billed Charges,115.74,58.75,,1267.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,92.59,47,,44.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,92.59,47,,44.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,92.59,47,,74.072,Percent of Total Billed Charges,47% of Total Billed Charges,92.59,47,,74.072,Percent of Total Billed Charges,47% of Total Billed Charges,92.59,177.3,
TUMS TAB,5020168,CDM,250,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,7.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,7.336,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,7.336,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,7.336,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
ZOCOR 40MG,5020169,CDM,259,RC,,,Outpatient,,,26.00,26.00,,15.28,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.28,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.59,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,23.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,23.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,12.22,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,23.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,15.28,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.22,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.22,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.22,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,12.22,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,12.22,23.4,
EPOGEN 10000 UNITS/PROCRIT,5020170,CDM,250,RC,,,Outpatient,,,546.00,546.00,,320.78,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,320.78,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,264.32,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,256.62,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,491.4,90,,393.12,Percent of Total Billed Charges,90% of Total Billed Charges,320.78,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,256.62,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,256.62,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,256.62,47,,205.296,Percent of Total Billed Charges,47% of Total Billed Charges,256.62,47,,205.296,Percent of Total Billed Charges,47% of Total Billed Charges,256.62,491.4,
DURAGESIC 100MG/HR,5020171,CDM,250,RC,,,Outpatient,,,350.00,350.00,,205.63,58.75,,167.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,205.63,58.75,,167.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,169.44,48.41,,11.232,Percent of Total Billed Charges,48.41% of Total Billed Charges,315,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,315,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,164.5,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,315,90,,252,Percent of Total Billed Charges,90% of Total Billed Charges,205.63,58.75,,167.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,164.5,47,,10.904,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,164.5,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,164.5,47,,131.6,Percent of Total Billed Charges,47% of Total Billed Charges,164.5,47,,131.6,Percent of Total Billed Charges,47% of Total Billed Charges,164.5,315,
ADVAIR DISKUS 28,5020172,CDM,259,RC,,,Outpatient,,,254.00,254.00,,149.23,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,149.23,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,122.96,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,228.6,90,,182.88,Percent of Total Billed Charges,90% of Total Billed Charges,228.6,90,,182.88,Percent of Total Billed Charges,90% of Total Billed Charges,119.38,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,228.6,90,,182.88,Percent of Total Billed Charges,90% of Total Billed Charges,149.23,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,119.38,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,119.38,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,119.38,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,119.38,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,119.38,228.6,
PRELONE SYRUP 5ML,5020173,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,13.944,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,13.536,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
XOPENEX UD,5020174,CDM,250,RC,,,Outpatient,,,15.75,15.75,,9.25,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.25,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.62,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.18,90,,11.344,Percent of Total Billed Charges,90% of Total Billed Charges,14.18,90,,11.344,Percent of Total Billed Charges,90% of Total Billed Charges,7.4,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,14.18,90,,11.344,Percent of Total Billed Charges,90% of Total Billed Charges,9.25,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.4,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.4,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.4,47,,5.92,Percent of Total Billed Charges,47% of Total Billed Charges,7.4,47,,5.92,Percent of Total Billed Charges,47% of Total Billed Charges,7.4,14.18,
PROTONIX 40 MG IV,5020176,CDM,250,RC,,,Outpatient,,,138.00,138.00,,81.08,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,81.08,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.81,48.41,,10.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,124.2,90,,99.36,Percent of Total Billed Charges,90% of Total Billed Charges,124.2,90,,99.36,Percent of Total Billed Charges,90% of Total Billed Charges,64.86,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,124.2,90,,99.36,Percent of Total Billed Charges,90% of Total Billed Charges,81.08,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,64.86,47,,10.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,64.86,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,64.86,47,,51.888,Percent of Total Billed Charges,47% of Total Billed Charges,64.86,47,,51.888,Percent of Total Billed Charges,47% of Total Billed Charges,64.86,124.2,
SPIRIVA SPINHALER,5020177,CDM,250,RC,,,Outpatient,,,74.80,74.80,,43.95,58.75,,38.256,Percent of Total Billed Charges,58.75% of Total Billed Charges,43.95,58.75,,38.256,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.21,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,67.32,90,,53.856,Percent of Total Billed Charges,90% of Total Billed Charges,67.32,90,,53.856,Percent of Total Billed Charges,90% of Total Billed Charges,35.16,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,67.32,90,,53.856,Percent of Total Billed Charges,90% of Total Billed Charges,43.95,58.75,,38.256,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.16,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,35.16,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.16,47,,28.128,Percent of Total Billed Charges,47% of Total Billed Charges,35.16,47,,28.128,Percent of Total Billed Charges,47% of Total Billed Charges,35.16,67.32,
SPIRIVA DOSE,5020178,CDM,250,RC,,,Outpatient,,,25.00,25.00,,14.69,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.69,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.1,48.41,,37.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,47,,36.472,Percent of Total Billed Charges,47% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,14.69,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,36.472,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.75,47,,36.472,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,22.5,
DEXFERRON 100 MG,5020179,CDM,250,RC,,,Outpatient,,,149.00,149.00,,87.54,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,87.54,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,72.13,48.41,,11.232,Percent of Total Billed Charges,48.41% of Total Billed Charges,134.1,90,,107.28,Percent of Total Billed Charges,90% of Total Billed Charges,134.1,90,,107.28,Percent of Total Billed Charges,90% of Total Billed Charges,70.03,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,134.1,90,,107.28,Percent of Total Billed Charges,90% of Total Billed Charges,87.54,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,70.03,47,,10.904,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,70.03,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,70.03,47,,56.024,Percent of Total Billed Charges,47% of Total Billed Charges,70.03,47,,56.024,Percent of Total Billed Charges,47% of Total Billed Charges,70.03,134.1,
ONDANSETRON 4 MG,5020180,CDM,250,RC,,,Outpatient,,,68.00,68.00,,39.95,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.95,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.92,48.41,,19.168,Percent of Total Billed Charges,48.41% of Total Billed Charges,61.2,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,61.2,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,31.96,47,,18.616,Percent of Total Billed Charges,47% of Total Billed Charges,61.2,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,39.95,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.96,47,,18.616,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.96,47,,18.616,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.96,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,31.96,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,31.96,61.2,
MIRALAX PWDR PER DOS,5020181,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,102.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,102.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,8.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,102.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,8.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MEGACC ES SUSP 5CC,5020182,CDM,259,RC,,,Outpatient,,,95.00,95.00,,55.81,58.75,,82.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,55.81,58.75,,82.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.99,48.41,,13.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,85.5,90,,68.4,Percent of Total Billed Charges,90% of Total Billed Charges,85.5,90,,68.4,Percent of Total Billed Charges,90% of Total Billed Charges,44.65,47,,13.2,Percent of Total Billed Charges,47% of Total Billed Charges,85.5,90,,68.4,Percent of Total Billed Charges,90% of Total Billed Charges,55.81,58.75,,82.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,44.65,47,,13.2,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,44.65,47,,13.2,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,44.65,47,,35.72,Percent of Total Billed Charges,47% of Total Billed Charges,44.65,47,,35.72,Percent of Total Billed Charges,47% of Total Billed Charges,44.65,85.5,
NEXIUM 40 MG IV,5020183,CDM,250,RC,,,Outpatient,,,111.35,111.35,,65.42,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,65.42,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,53.9,48.41,,13.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,100.22,90,,80.176,Percent of Total Billed Charges,90% of Total Billed Charges,100.22,90,,80.176,Percent of Total Billed Charges,90% of Total Billed Charges,52.33,47,,12.744,Percent of Total Billed Charges,47% of Total Billed Charges,100.22,90,,80.176,Percent of Total Billed Charges,90% of Total Billed Charges,65.42,58.75,,9.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,52.33,47,,12.744,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,52.33,47,,12.744,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,52.33,47,,41.864,Percent of Total Billed Charges,47% of Total Billed Charges,52.33,47,,41.864,Percent of Total Billed Charges,47% of Total Billed Charges,52.33,100.22,
LEVEMIR INSULIN,5020184,CDM,250,RC,,,Outpatient,,,46.20,46.20,,27.14,58.75,,42.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.14,58.75,,42.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.37,48.41,,8.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,41.58,90,,33.264,Percent of Total Billed Charges,90% of Total Billed Charges,41.58,90,,33.264,Percent of Total Billed Charges,90% of Total Billed Charges,21.71,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,41.58,90,,33.264,Percent of Total Billed Charges,90% of Total Billed Charges,27.14,58.75,,42.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.71,47,,8.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,21.71,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.71,47,,17.368,Percent of Total Billed Charges,47% of Total Billed Charges,21.71,47,,17.368,Percent of Total Billed Charges,47% of Total Billed Charges,21.71,41.58,
IODOSORB GEL,5020185,CDM,250,RC,,,Outpatient,,,300.30,300.30,,176.43,58.75,,53.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,176.43,58.75,,53.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.38,48.41,,4354.888,Percent of Total Billed Charges,48.41% of Total Billed Charges,270.27,90,,216.216,Percent of Total Billed Charges,90% of Total Billed Charges,270.27,90,,216.216,Percent of Total Billed Charges,90% of Total Billed Charges,141.14,47,,4228.048,Percent of Total Billed Charges,47% of Total Billed Charges,270.27,90,,216.216,Percent of Total Billed Charges,90% of Total Billed Charges,176.43,58.75,,53.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,141.14,47,,4228.048,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,141.14,47,,4228.048,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,141.14,47,,112.912,Percent of Total Billed Charges,47% of Total Billed Charges,141.14,47,,112.912,Percent of Total Billed Charges,47% of Total Billed Charges,141.14,270.27,
PRO-STAT,5020186,CDM,259,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,42.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,42.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,3.832,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,3.72,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,42.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,3.72,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,3.72,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
MIRALAX PWDR,5020187,CDM,259,RC,,,Outpatient,,,10.00,10.00,,5.88,58.75,,42.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.88,58.75,,42.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.84,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,9,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,9,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,9,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,5.88,58.75,,42.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.7,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,9,
TAMIFLU 75 MG,5020188,CDM,259,RC,,,Outpatient,,,35.00,35.00,,20.56,58.75,,93.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.56,58.75,,93.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.94,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,31.5,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,31.5,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,31.5,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,20.56,58.75,,93.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.45,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.45,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.45,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,16.45,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,16.45,31.5,
MOBIC 15MG,5020191,CDM,259,RC,,,Outpatient,,,23.00,23.00,,13.51,58.75,,1238.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.51,58.75,,1238.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.13,48.41,,6.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,10.81,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,13.51,58.75,,1238.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,6.016,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.81,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,20.7,
MOBIC 7.5MG,5020192,CDM,259,RC,,,Outpatient,,,13.75,13.75,,8.08,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.08,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.66,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.38,90,,9.904,Percent of Total Billed Charges,90% of Total Billed Charges,12.38,90,,9.904,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,12.38,90,,9.904,Percent of Total Billed Charges,90% of Total Billed Charges,8.08,58.75,,46.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.46,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.46,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.46,47,,5.168,Percent of Total Billed Charges,47% of Total Billed Charges,6.46,47,,5.168,Percent of Total Billed Charges,47% of Total Billed Charges,6.46,12.38,
ARANESP 150 MG,5020193,CDM,250,RC,,,Outpatient,,,4863.00,4863.00,,2857.01,58.75,,85.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,2857.01,58.75,,85.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,2354.18,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,4376.7,90,,3501.36,Percent of Total Billed Charges,90% of Total Billed Charges,4376.7,90,,3501.36,Percent of Total Billed Charges,90% of Total Billed Charges,2285.61,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,4376.7,90,,3501.36,Percent of Total Billed Charges,90% of Total Billed Charges,2857.01,58.75,,85.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2285.61,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2285.61,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2285.61,47,,1828.488,Percent of Total Billed Charges,47% of Total Billed Charges,2285.61,47,,1828.488,Percent of Total Billed Charges,47% of Total Billed Charges,2285.61,4376.7,
RECLAST,5020194,CDM,250,RC,,,Outpatient,,,3850.00,3850.00,,2261.88,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,2261.88,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,1863.79,48.41,,6.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,3465,90,,2772,Percent of Total Billed Charges,90% of Total Billed Charges,3465,90,,2772,Percent of Total Billed Charges,90% of Total Billed Charges,1809.5,47,,6.296,Percent of Total Billed Charges,47% of Total Billed Charges,3465,90,,2772,Percent of Total Billed Charges,90% of Total Billed Charges,2261.88,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1809.5,47,,6.296,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1809.5,47,,6.296,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1809.5,47,,1447.6,Percent of Total Billed Charges,47% of Total Billed Charges,1809.5,47,,1447.6,Percent of Total Billed Charges,47% of Total Billed Charges,1809.5,3465,
PANAFIL 30 GM,5020196,CDM,270,RC,,,Outpatient,,,291.00,291.00,,170.96,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,170.96,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,140.87,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,261.9,90,,209.52,Percent of Total Billed Charges,90% of Total Billed Charges,261.9,90,,209.52,Percent of Total Billed Charges,90% of Total Billed Charges,136.77,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,261.9,90,,209.52,Percent of Total Billed Charges,90% of Total Billed Charges,170.96,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,136.77,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,136.77,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,136.77,47,,109.416,Percent of Total Billed Charges,47% of Total Billed Charges,136.77,47,,109.416,Percent of Total Billed Charges,47% of Total Billed Charges,136.77,261.9,
FLONASE NASAL SPRAY,5020197,CDM,259,RC,,,Outpatient,,,249.00,249.00,,146.29,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,146.29,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,120.54,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,224.1,90,,179.28,Percent of Total Billed Charges,90% of Total Billed Charges,224.1,90,,179.28,Percent of Total Billed Charges,90% of Total Billed Charges,117.03,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,224.1,90,,179.28,Percent of Total Billed Charges,90% of Total Billed Charges,146.29,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,117.03,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,117.03,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,117.03,47,,93.624,Percent of Total Billed Charges,47% of Total Billed Charges,117.03,47,,93.624,Percent of Total Billed Charges,47% of Total Billed Charges,117.03,224.1,
ALBUMIN 25% 50CC IV,5020198,CDM,250,RC,,,Outpatient,,,372.00,372.00,,218.55,58.75,,11565.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,218.55,58.75,,11565.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,180.09,48.41,,11.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,334.8,90,,267.84,Percent of Total Billed Charges,90% of Total Billed Charges,334.8,90,,267.84,Percent of Total Billed Charges,90% of Total Billed Charges,174.84,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,334.8,90,,267.84,Percent of Total Billed Charges,90% of Total Billed Charges,218.55,58.75,,11565.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,174.84,47,,11.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,174.84,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,174.84,47,,139.872,Percent of Total Billed Charges,47% of Total Billed Charges,174.84,47,,139.872,Percent of Total Billed Charges,47% of Total Billed Charges,174.84,334.8,
AMOXIL 400/5 SUSP,5020199,CDM,259,RC,,,Outpatient,,,37.00,37.00,,21.74,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.74,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.91,48.41,,10.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,33.3,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,33.3,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,17.39,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,33.3,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,21.74,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.39,47,,9.776,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.39,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.39,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,17.39,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,17.39,33.3,
AMOXIL 200/5 SUSP,5020200,CDM,259,RC,,,Outpatient,,,37.50,37.50,,22.03,58.75,,136.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.03,58.75,,136.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.15,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,33.75,90,,27,Percent of Total Billed Charges,90% of Total Billed Charges,33.75,90,,27,Percent of Total Billed Charges,90% of Total Billed Charges,17.63,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,33.75,90,,27,Percent of Total Billed Charges,90% of Total Billed Charges,22.03,58.75,,136.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.63,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.63,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.63,47,,14.104,Percent of Total Billed Charges,47% of Total Billed Charges,17.63,47,,14.104,Percent of Total Billed Charges,47% of Total Billed Charges,17.63,33.75,
REMICADE 100 MG,5020201,CDM,250,RC,,,Outpatient,,,2697.00,2697.00,,1584.49,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,1584.49,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,1305.62,48.41,,871.768,Percent of Total Billed Charges,48.41% of Total Billed Charges,2427.3,90,,1941.84,Percent of Total Billed Charges,90% of Total Billed Charges,2427.3,90,,1941.84,Percent of Total Billed Charges,90% of Total Billed Charges,1267.59,47,,846.376,Percent of Total Billed Charges,47% of Total Billed Charges,2427.3,90,,1941.84,Percent of Total Billed Charges,90% of Total Billed Charges,1584.49,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1267.59,47,,846.376,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1267.59,47,,846.376,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1267.59,47,,1014.072,Percent of Total Billed Charges,47% of Total Billed Charges,1267.59,47,,1014.072,Percent of Total Billed Charges,47% of Total Billed Charges,1267.59,2427.3,
ZINC TAB,5020202,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,11.04,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,10.72,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,31.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,10.72,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,10.72,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
DIOVAN 80 MG,5020203,CDM,259,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,2107.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,2107.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,297.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,289.144,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,2107.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,289.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,289.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
DUONEB,5020204,CDM,250,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,35.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,35.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,36.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,35.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,35.344,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
HALDOL DECANOATE 100,5020205,CDM,250,RC,,,Outpatient,,,356.00,356.00,,209.15,58.75,,40.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,209.15,58.75,,40.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,172.34,48.41,,81.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,320.4,90,,256.32,Percent of Total Billed Charges,90% of Total Billed Charges,320.4,90,,256.32,Percent of Total Billed Charges,90% of Total Billed Charges,167.32,47,,78.96,Percent of Total Billed Charges,47% of Total Billed Charges,320.4,90,,256.32,Percent of Total Billed Charges,90% of Total Billed Charges,209.15,58.75,,40.424,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,167.32,47,,78.96,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,167.32,47,,78.96,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,167.32,47,,133.856,Percent of Total Billed Charges,47% of Total Billed Charges,167.32,47,,133.856,Percent of Total Billed Charges,47% of Total Billed Charges,167.32,320.4,
ASPIRIN 81MG CHEWABL,5020206,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,1760.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,1760.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,3.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,1760.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,3.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
BUDESONIDE .5MG/2 ML,5020207,CDM,250,RC,,,Outpatient,,,37.00,37.00,,21.74,58.75,,2499.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.74,58.75,,2499.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.91,48.41,,44.536,Percent of Total Billed Charges,48.41% of Total Billed Charges,33.3,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,33.3,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,17.39,47,,43.24,Percent of Total Billed Charges,47% of Total Billed Charges,33.3,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,21.74,58.75,,2499.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.39,47,,43.24,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.39,47,,43.24,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.39,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,17.39,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,17.39,33.3,
PHOSPHORUS 250 MG,5020208,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,2400.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2400.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,2400.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
SIMETHICONE 80 MG TB,5020209,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
ZITHROMAX 500 MG TAB,5020210,CDM,259,RC,,,Outpatient,,,81.40,81.40,,47.82,58.75,,628.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.82,58.75,,628.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.41,48.41,,123.544,Percent of Total Billed Charges,48.41% of Total Billed Charges,73.26,90,,58.608,Percent of Total Billed Charges,90% of Total Billed Charges,73.26,90,,58.608,Percent of Total Billed Charges,90% of Total Billed Charges,38.26,47,,119.944,Percent of Total Billed Charges,47% of Total Billed Charges,73.26,90,,58.608,Percent of Total Billed Charges,90% of Total Billed Charges,47.82,58.75,,628.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.26,47,,119.944,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,38.26,47,,119.944,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,38.26,47,,30.608,Percent of Total Billed Charges,47% of Total Billed Charges,38.26,47,,30.608,Percent of Total Billed Charges,47% of Total Billed Charges,38.26,73.26,
LEXAPRO 5 MG,5020211,CDM,259,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,8.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,8.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,96.824,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,94,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,8.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,94,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,94,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
HALL'S COUGH DROP,5020212,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,9.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,9.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,45.696,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,44.368,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,9.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,44.368,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,44.368,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
IMODIUM LIQ 5 CC,5020213,CDM,259,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,55.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,55.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,66.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,64.672,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,55.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,64.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,64.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DURAGESIC 75 MCG/HR,5020214,CDM,259,RC,,,Outpatient,,,218.00,218.00,,128.08,58.75,,9.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,128.08,58.75,,9.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,105.53,48.41,,197.512,Percent of Total Billed Charges,48.41% of Total Billed Charges,196.2,90,,156.96,Percent of Total Billed Charges,90% of Total Billed Charges,196.2,90,,156.96,Percent of Total Billed Charges,90% of Total Billed Charges,102.46,47,,191.76,Percent of Total Billed Charges,47% of Total Billed Charges,196.2,90,,156.96,Percent of Total Billed Charges,90% of Total Billed Charges,128.08,58.75,,9.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,102.46,47,,191.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,102.46,47,,191.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,102.46,47,,81.968,Percent of Total Billed Charges,47% of Total Billed Charges,102.46,47,,81.968,Percent of Total Billed Charges,47% of Total Billed Charges,102.46,196.2,
ZOSYN 2.25 GM,5020215,CDM,250,RC,,,Outpatient,,,176.00,176.00,,103.4,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,103.4,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,85.2,48.41,,80.944,Percent of Total Billed Charges,48.41% of Total Billed Charges,158.4,90,,126.72,Percent of Total Billed Charges,90% of Total Billed Charges,158.4,90,,126.72,Percent of Total Billed Charges,90% of Total Billed Charges,82.72,47,,78.584,Percent of Total Billed Charges,47% of Total Billed Charges,158.4,90,,126.72,Percent of Total Billed Charges,90% of Total Billed Charges,103.4,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,82.72,47,,78.584,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,82.72,47,,78.584,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,82.72,47,,66.176,Percent of Total Billed Charges,47% of Total Billed Charges,82.72,47,,66.176,Percent of Total Billed Charges,47% of Total Billed Charges,82.72,158.4,
LASIX 100 MG/10ML,5020216,CDM,250,RC,,,Outpatient,,,21.00,21.00,,12.34,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.34,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.17,48.41,,33.696,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.9,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,18.9,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,9.87,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,18.9,90,,15.12,Percent of Total Billed Charges,90% of Total Billed Charges,12.34,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.87,47,,32.712,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.87,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.87,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,47,,7.896,Percent of Total Billed Charges,47% of Total Billed Charges,9.87,18.9,
GI COCKTAIL 30 ML,5020217,CDM,259,RC,,,Outpatient,,,91.00,91.00,,53.46,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,53.46,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.05,48.41,,24.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,81.9,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,81.9,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,42.77,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,81.9,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,53.46,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,42.77,47,,24.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,42.77,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,42.77,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,42.77,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,42.77,81.9,
EMLA CREAM,5020218,CDM,270,RC,,,Outpatient,,,114.00,114.00,,66.98,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.98,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,55.19,48.41,,152.976,Percent of Total Billed Charges,48.41% of Total Billed Charges,102.6,90,,82.08,Percent of Total Billed Charges,90% of Total Billed Charges,102.6,90,,82.08,Percent of Total Billed Charges,90% of Total Billed Charges,53.58,47,,148.52,Percent of Total Billed Charges,47% of Total Billed Charges,102.6,90,,82.08,Percent of Total Billed Charges,90% of Total Billed Charges,66.98,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,53.58,47,,148.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,53.58,47,,148.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,53.58,47,,42.864,Percent of Total Billed Charges,47% of Total Billed Charges,53.58,47,,42.864,Percent of Total Billed Charges,47% of Total Billed Charges,53.58,102.6,
LIDOCAINE OINT 5%,5020219,CDM,270,RC,,,Outpatient,,,91.00,91.00,,53.46,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,53.46,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.05,48.41,,154.528,Percent of Total Billed Charges,48.41% of Total Billed Charges,81.9,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,81.9,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,42.77,47,,150.024,Percent of Total Billed Charges,47% of Total Billed Charges,81.9,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,53.46,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,42.77,47,,150.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,42.77,47,,150.024,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,42.77,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,42.77,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,42.77,81.9,
NITROPRESS,5020220,CDM,250,RC,,,Outpatient,,,91.00,91.00,,53.46,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,53.46,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.05,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,81.9,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,81.9,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,42.77,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,81.9,90,,65.52,Percent of Total Billed Charges,90% of Total Billed Charges,53.46,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,42.77,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,42.77,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,42.77,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,42.77,47,,34.216,Percent of Total Billed Charges,47% of Total Billed Charges,42.77,81.9,
DIFLUCAN IV200MG/100,5020221,CDM,250,RC,,,Outpatient,,,199.10,199.10,,116.97,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,116.97,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.38,48.41,,797.8,Percent of Total Billed Charges,48.41% of Total Billed Charges,179.19,90,,143.352,Percent of Total Billed Charges,90% of Total Billed Charges,179.19,90,,143.352,Percent of Total Billed Charges,90% of Total Billed Charges,93.58,47,,774.56,Percent of Total Billed Charges,47% of Total Billed Charges,179.19,90,,143.352,Percent of Total Billed Charges,90% of Total Billed Charges,116.97,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,93.58,47,,774.56,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,93.58,47,,774.56,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,93.58,47,,74.864,Percent of Total Billed Charges,47% of Total Billed Charges,93.58,47,,74.864,Percent of Total Billed Charges,47% of Total Billed Charges,93.58,179.19,
PROLIA 60 MG,5020222,CDM,250,RC,,,Outpatient,,,2636.00,2636.00,,1548.65,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,1548.65,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,1276.09,48.41,,424.848,Percent of Total Billed Charges,48.41% of Total Billed Charges,2372.4,90,,1897.92,Percent of Total Billed Charges,90% of Total Billed Charges,2372.4,90,,1897.92,Percent of Total Billed Charges,90% of Total Billed Charges,1238.92,47,,412.472,Percent of Total Billed Charges,47% of Total Billed Charges,2372.4,90,,1897.92,Percent of Total Billed Charges,90% of Total Billed Charges,1548.65,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1238.92,47,,412.472,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1238.92,47,,412.472,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1238.92,47,,991.136,Percent of Total Billed Charges,47% of Total Billed Charges,1238.92,47,,991.136,Percent of Total Billed Charges,47% of Total Billed Charges,1238.92,2372.4,
DIFLUCAN 200 MGORAL,5020223,CDM,259,RC,,,Outpatient,,,98.00,98.00,,57.58,58.75,,45.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.58,58.75,,45.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.44,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,88.2,90,,70.56,Percent of Total Billed Charges,90% of Total Billed Charges,88.2,90,,70.56,Percent of Total Billed Charges,90% of Total Billed Charges,46.06,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,88.2,90,,70.56,Percent of Total Billed Charges,90% of Total Billed Charges,57.58,58.75,,45.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.06,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,46.06,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.06,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,46.06,47,,36.848,Percent of Total Billed Charges,47% of Total Billed Charges,46.06,88.2,
VASOLEX OINTMENT,5020224,CDM,259,RC,,,Outpatient,,,181.00,181.00,,106.34,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,106.34,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,87.62,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,162.9,90,,130.32,Percent of Total Billed Charges,90% of Total Billed Charges,162.9,90,,130.32,Percent of Total Billed Charges,90% of Total Billed Charges,85.07,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,162.9,90,,130.32,Percent of Total Billed Charges,90% of Total Billed Charges,106.34,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,85.07,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,85.07,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,85.07,47,,68.056,Percent of Total Billed Charges,47% of Total Billed Charges,85.07,47,,68.056,Percent of Total Billed Charges,47% of Total Billed Charges,85.07,162.9,
LOPRESSOR 25 MG,5020226,CDM,259,RC,,,Outpatient,,,9.00,9.00,,5.29,58.75,,23.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.29,58.75,,23.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.36,48.41,,186.28,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.1,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,47,,180.856,Percent of Total Billed Charges,47% of Total Billed Charges,8.1,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,58.75,,23.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,180.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.23,47,,180.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,8.1,
MAXZIDE 25,5020227,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,1220.704,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,1185.152,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,1185.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,1185.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
VECURONIUM 10MG/10ML,5020228,CDM,250,RC,,,Outpatient,,,36.00,36.00,,21.15,58.75,,16.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.15,58.75,,16.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.43,48.41,,1558.8,Percent of Total Billed Charges,48.41% of Total Billed Charges,32.4,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,32.4,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,16.92,47,,1513.4,Percent of Total Billed Charges,47% of Total Billed Charges,32.4,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,58.75,,16.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.92,47,,1513.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.92,47,,1513.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.92,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,16.92,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,16.92,32.4,
ACTIVASE 100 MG,5020229,CDM,250,RC,,,Outpatient,,,24608.00,24608.00,,14457.2,58.75,,15.936,Percent of Total Billed Charges,58.75% of Total Billed Charges,14457.2,58.75,,15.936,Percent of Total Billed Charges,58.75% of Total Billed Charges,11912.73,48.41,,46.472,Percent of Total Billed Charges,48.41% of Total Billed Charges,22147.2,90,,17717.76,Percent of Total Billed Charges,90% of Total Billed Charges,22147.2,90,,17717.76,Percent of Total Billed Charges,90% of Total Billed Charges,11565.76,47,,45.12,Percent of Total Billed Charges,47% of Total Billed Charges,22147.2,90,,17717.76,Percent of Total Billed Charges,90% of Total Billed Charges,14457.2,58.75,,15.936,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11565.76,47,,45.12,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11565.76,47,,45.12,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11565.76,47,,9252.608,Percent of Total Billed Charges,47% of Total Billed Charges,11565.76,47,,9252.608,Percent of Total Billed Charges,47% of Total Billed Charges,11565.76,22147.2,
HYDROCODONE/APAP 5/325 MG,5020230,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,22.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,21.432,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
FLUZONE HIGH DOSE,5020231,CDM,250,RC,,,Outpatient,,,291.00,291.00,,170.96,58.75,,5285.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,170.96,58.75,,5285.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,140.87,48.41,,3020.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,261.9,90,,209.52,Percent of Total Billed Charges,90% of Total Billed Charges,261.9,90,,209.52,Percent of Total Billed Charges,90% of Total Billed Charges,136.77,47,,2932.8,Percent of Total Billed Charges,47% of Total Billed Charges,261.9,90,,209.52,Percent of Total Billed Charges,90% of Total Billed Charges,170.96,58.75,,4228.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,136.77,47,,2932.8,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,136.77,47,,2932.8,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,136.77,47,,109.416,Percent of Total Billed Charges,47% of Total Billed Charges,136.77,47,,109.416,Percent of Total Billed Charges,47% of Total Billed Charges,136.77,261.9,
TAMIFLU SUSP 1 ML,5020232,CDM,259,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,4.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,4.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,889.192,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,863.296,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,4.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,863.296,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,863.296,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
FLUZONE INTRADERMAL,5020233,CDM,250,RC,,,Outpatient,,,66.00,66.00,,38.78,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.78,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.95,48.41,,15.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,59.4,90,,47.52,Percent of Total Billed Charges,90% of Total Billed Charges,59.4,90,,47.52,Percent of Total Billed Charges,90% of Total Billed Charges,31.02,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,59.4,90,,47.52,Percent of Total Billed Charges,90% of Total Billed Charges,38.78,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.02,47,,15.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.02,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.02,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,31.02,47,,24.816,Percent of Total Billed Charges,47% of Total Billed Charges,31.02,59.4,
MAKENA INJ,5020234,CDM,250,RC,,,Outpatient,,,4485.00,4485.00,,2634.94,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,2634.94,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,2171.19,48.41,,384.184,Percent of Total Billed Charges,48.41% of Total Billed Charges,4036.5,90,,3229.2,Percent of Total Billed Charges,90% of Total Billed Charges,4036.5,90,,3229.2,Percent of Total Billed Charges,90% of Total Billed Charges,2107.95,47,,372.992,Percent of Total Billed Charges,47% of Total Billed Charges,4036.5,90,,3229.2,Percent of Total Billed Charges,90% of Total Billed Charges,2634.94,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2107.95,47,,372.992,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2107.95,47,,372.992,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2107.95,47,,1686.36,Percent of Total Billed Charges,47% of Total Billed Charges,2107.95,47,,1686.36,Percent of Total Billed Charges,47% of Total Billed Charges,2107.95,4036.5,
POT CHL ELIXIR 20% 40MEQ/15ML,5020235,CDM,259,RC,,,Outpatient,,,76.00,76.00,,44.65,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.65,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.79,48.41,,351.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,68.4,90,,54.72,Percent of Total Billed Charges,90% of Total Billed Charges,68.4,90,,54.72,Percent of Total Billed Charges,90% of Total Billed Charges,35.72,47,,341.408,Percent of Total Billed Charges,47% of Total Billed Charges,68.4,90,,54.72,Percent of Total Billed Charges,90% of Total Billed Charges,44.65,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.72,47,,341.408,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,35.72,47,,341.408,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.72,47,,28.576,Percent of Total Billed Charges,47% of Total Billed Charges,35.72,47,,28.576,Percent of Total Billed Charges,47% of Total Billed Charges,35.72,68.4,
FLU PEDS VACCINE,5020236,CDM,250,RC,,,Outpatient,,,86.00,86.00,,50.53,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.53,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.63,48.41,,696.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,77.4,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,77.4,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,40.42,47,,676.424,Percent of Total Billed Charges,47% of Total Billed Charges,77.4,90,,61.92,Percent of Total Billed Charges,90% of Total Billed Charges,50.53,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.42,47,,676.424,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.42,47,,676.424,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.42,47,,32.336,Percent of Total Billed Charges,47% of Total Billed Charges,40.42,47,,32.336,Percent of Total Billed Charges,47% of Total Billed Charges,40.42,77.4,
ARANESP 200MCG,5020237,CDM,250,RC,,,Outpatient,,,3745.00,3745.00,,2200.19,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,2200.19,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,1812.95,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,3370.5,90,,2696.4,Percent of Total Billed Charges,90% of Total Billed Charges,3370.5,90,,2696.4,Percent of Total Billed Charges,90% of Total Billed Charges,1760.15,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,3370.5,90,,2696.4,Percent of Total Billed Charges,90% of Total Billed Charges,2200.19,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1760.15,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1760.15,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1760.15,47,,1408.12,Percent of Total Billed Charges,47% of Total Billed Charges,1760.15,47,,1408.12,Percent of Total Billed Charges,47% of Total Billed Charges,1760.15,3370.5,
ARANESP 500,5020238,CDM,250,RC,,,Outpatient,,,5319.00,5319.00,,3124.91,58.75,,7.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,3124.91,58.75,,7.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,2574.93,48.41,,33.696,Percent of Total Billed Charges,48.41% of Total Billed Charges,4787.1,90,,3829.68,Percent of Total Billed Charges,90% of Total Billed Charges,4787.1,90,,3829.68,Percent of Total Billed Charges,90% of Total Billed Charges,2499.93,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,4787.1,90,,3829.68,Percent of Total Billed Charges,90% of Total Billed Charges,3124.91,58.75,,7.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2499.93,47,,32.712,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2499.93,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2499.93,47,,1999.944,Percent of Total Billed Charges,47% of Total Billed Charges,2499.93,47,,1999.944,Percent of Total Billed Charges,47% of Total Billed Charges,2499.93,4787.1,
ARANESP 300MCG,5020239,CDM,250,RC,,,Outpatient,,,5107.00,5107.00,,3000.36,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,3000.36,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2472.3,48.41,,46.088,Percent of Total Billed Charges,48.41% of Total Billed Charges,4596.3,90,,3677.04,Percent of Total Billed Charges,90% of Total Billed Charges,4596.3,90,,3677.04,Percent of Total Billed Charges,90% of Total Billed Charges,2400.29,47,,44.744,Percent of Total Billed Charges,47% of Total Billed Charges,4596.3,90,,3677.04,Percent of Total Billed Charges,90% of Total Billed Charges,3000.36,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2400.29,47,,44.744,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2400.29,47,,44.744,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2400.29,47,,1920.232,Percent of Total Billed Charges,47% of Total Billed Charges,2400.29,47,,1920.232,Percent of Total Billed Charges,47% of Total Billed Charges,2400.29,4596.3,
FORTAZ 1GM,5020240,CDM,250,RC,,,Outpatient,,,71.00,71.00,,41.71,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.71,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.37,48.41,,27.888,Percent of Total Billed Charges,48.41% of Total Billed Charges,63.9,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,63.9,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,33.37,47,,27.072,Percent of Total Billed Charges,47% of Total Billed Charges,63.9,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,41.71,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.37,47,,27.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,33.37,47,,27.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.37,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,33.37,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,33.37,63.9,
CUBICIN 500MG,5020241,CDM,250,RC,,,Outpatient,,,1338.00,1338.00,,786.08,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,786.08,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,647.73,48.41,,29.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,1204.2,90,,963.36,Percent of Total Billed Charges,90% of Total Billed Charges,1204.2,90,,963.36,Percent of Total Billed Charges,90% of Total Billed Charges,628.86,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,1204.2,90,,963.36,Percent of Total Billed Charges,90% of Total Billed Charges,786.08,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,628.86,47,,28.2,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,628.86,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,628.86,47,,503.088,Percent of Total Billed Charges,47% of Total Billed Charges,628.86,47,,503.088,Percent of Total Billed Charges,47% of Total Billed Charges,628.86,1204.2,
IRRG NORMAL SALINE,5021006,CDM,258,RC,,,Outpatient,,,18.70,18.70,,10.99,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.99,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.05,48.41,,58.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.83,90,,13.464,Percent of Total Billed Charges,90% of Total Billed Charges,16.83,90,,13.464,Percent of Total Billed Charges,90% of Total Billed Charges,8.79,47,,56.4,Percent of Total Billed Charges,47% of Total Billed Charges,16.83,90,,13.464,Percent of Total Billed Charges,90% of Total Billed Charges,10.99,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.79,47,,56.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.79,47,,56.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.79,47,,7.032,Percent of Total Billed Charges,47% of Total Billed Charges,8.79,47,,7.032,Percent of Total Billed Charges,47% of Total Billed Charges,8.79,16.83,
IRRIG WATER,5021014,CDM,258,RC,,,Outpatient,,,20.60,20.60,,12.1,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.1,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.97,48.41,,230.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.54,90,,14.832,Percent of Total Billed Charges,90% of Total Billed Charges,18.54,90,,14.832,Percent of Total Billed Charges,90% of Total Billed Charges,9.68,47,,223.344,Percent of Total Billed Charges,47% of Total Billed Charges,18.54,90,,14.832,Percent of Total Billed Charges,90% of Total Billed Charges,12.1,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.68,47,,223.344,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.68,47,,223.344,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.68,47,,7.744,Percent of Total Billed Charges,47% of Total Billed Charges,9.68,47,,7.744,Percent of Total Billed Charges,47% of Total Billed Charges,9.68,18.54,
DOPAMINE 400/500ML,5022002,CDM,250,RC,,,Outpatient,,,117.70,117.70,,69.15,58.75,,1057.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.15,58.75,,1057.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,56.98,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,105.93,90,,84.744,Percent of Total Billed Charges,90% of Total Billed Charges,105.93,90,,84.744,Percent of Total Billed Charges,90% of Total Billed Charges,55.32,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,105.93,90,,84.744,Percent of Total Billed Charges,90% of Total Billed Charges,69.15,58.75,,1057.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.32,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,55.32,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.32,47,,44.256,Percent of Total Billed Charges,47% of Total Billed Charges,55.32,47,,44.256,Percent of Total Billed Charges,47% of Total Billed Charges,55.32,105.93,
IV D5 1/4NS 500ML,5027038,CDM,260,RC,,,Outpatient,,,19.50,19.50,,11.46,58.75,,13.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.46,58.75,,13.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.44,48.41,,46.008,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.55,90,,14.04,Percent of Total Billed Charges,90% of Total Billed Charges,17.55,90,,14.04,Percent of Total Billed Charges,90% of Total Billed Charges,9.17,47,,44.672,Percent of Total Billed Charges,47% of Total Billed Charges,17.55,90,,14.04,Percent of Total Billed Charges,90% of Total Billed Charges,11.46,58.75,,13.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.17,47,,44.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.17,47,,44.672,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,9.17,47,,7.336,Percent of Total Billed Charges,47% of Total Billed Charges,9.17,47,,7.336,Percent of Total Billed Charges,47% of Total Billed Charges,9.17,150,
D5W1/2 N S 1000ML,5027045,CDM,258,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,361.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,361.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,361.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
D5W1/2 N S 500ML,5027047,CDM,258,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,3.832,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,3.72,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,3.72,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,3.72,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
D5 NS 1000,5027054,CDM,258,RC,,,Outpatient,,,29.00,29.00,,17.04,58.75,,98.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.04,58.75,,98.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.04,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,26.1,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,26.1,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,13.63,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,26.1,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,17.04,58.75,,98.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.63,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.63,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.63,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,13.63,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,13.63,26.1,
DEX 5%LR 500CC,5027056,CDM,258,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
D5W 1000,5027062,CDM,258,RC,,,Outpatient,,,36.00,36.00,,21.15,58.75,,54.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.15,58.75,,54.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.43,48.41,,76.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,32.4,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,32.4,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,16.92,47,,74.448,Percent of Total Billed Charges,47% of Total Billed Charges,32.4,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,58.75,,54.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.92,47,,74.448,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.92,47,,74.448,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.92,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,16.92,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,16.92,32.4,
IV D5W 250 ML,5027064,CDM,258,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,21.688,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,21.056,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,21.056,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,21.056,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
IV D5W 500ML,5027065,CDM,258,RC,,,Outpatient,,,27.00,27.00,,15.86,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.86,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.07,48.41,,9.296,Percent of Total Billed Charges,48.41% of Total Billed Charges,24.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,24.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,12.69,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,24.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,15.86,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,9.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.69,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,24.3,
D5 LR 1000,5027067,CDM,258,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,149.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,149.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,149.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
LR 1000,5027112,CDM,258,RC,,,Outpatient,,,97.00,97.00,,56.99,58.75,,117.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,56.99,58.75,,117.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.96,48.41,,38.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,87.3,90,,69.84,Percent of Total Billed Charges,90% of Total Billed Charges,87.3,90,,69.84,Percent of Total Billed Charges,90% of Total Billed Charges,45.59,47,,37.224,Percent of Total Billed Charges,47% of Total Billed Charges,87.3,90,,69.84,Percent of Total Billed Charges,90% of Total Billed Charges,56.99,58.75,,117.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.59,47,,37.224,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,45.59,47,,37.224,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.59,47,,36.472,Percent of Total Billed Charges,47% of Total Billed Charges,45.59,47,,36.472,Percent of Total Billed Charges,47% of Total Billed Charges,45.59,87.3,
NS 1000,5027129,CDM,258,RC,,,Outpatient,,,29.00,29.00,,17.04,58.75,,55.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.04,58.75,,55.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.04,48.41,,18.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,26.1,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,26.1,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,13.63,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,26.1,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,17.04,58.75,,55.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.63,47,,17.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.63,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.63,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,13.63,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,13.63,26.1,
N S 0.9% 100ML P/F,5027130,CDM,258,RC,,,Outpatient,,,49.50,49.50,,29.08,58.75,,80.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.08,58.75,,80.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.96,48.41,,218.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,44.55,90,,35.64,Percent of Total Billed Charges,90% of Total Billed Charges,44.55,90,,35.64,Percent of Total Billed Charges,90% of Total Billed Charges,23.27,47,,212.064,Percent of Total Billed Charges,47% of Total Billed Charges,44.55,90,,35.64,Percent of Total Billed Charges,90% of Total Billed Charges,29.08,58.75,,80.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.27,47,,212.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.27,47,,212.064,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.27,47,,18.616,Percent of Total Billed Charges,47% of Total Billed Charges,23.27,47,,18.616,Percent of Total Billed Charges,47% of Total Billed Charges,23.27,44.55,
NS 250,5027132,CDM,258,RC,,,Outpatient,,,23.00,23.00,,13.51,58.75,,239.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.51,58.75,,239.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.13,48.41,,67.384,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,10.81,47,,65.424,Percent of Total Billed Charges,47% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,13.51,58.75,,239.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,65.424,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.81,47,,65.424,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,20.7,
NS 500,5027133,CDM,258,RC,,,Outpatient,,,35.10,35.10,,20.62,58.75,,98.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.62,58.75,,98.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.99,48.41,,26.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,31.59,90,,25.272,Percent of Total Billed Charges,90% of Total Billed Charges,31.59,90,,25.272,Percent of Total Billed Charges,90% of Total Billed Charges,16.5,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,31.59,90,,25.272,Percent of Total Billed Charges,90% of Total Billed Charges,20.62,58.75,,98.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.5,47,,25.944,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.5,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.5,47,,13.2,Percent of Total Billed Charges,47% of Total Billed Charges,16.5,47,,13.2,Percent of Total Billed Charges,47% of Total Billed Charges,16.5,31.59,
1/2 NS 1000,5029074,CDM,258,RC,,,Outpatient,,,33.90,33.90,,19.92,58.75,,40.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.92,58.75,,40.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.41,48.41,,14.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,30.51,90,,24.408,Percent of Total Billed Charges,90% of Total Billed Charges,30.51,90,,24.408,Percent of Total Billed Charges,90% of Total Billed Charges,15.93,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,30.51,90,,24.408,Percent of Total Billed Charges,90% of Total Billed Charges,19.92,58.75,,40.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.93,47,,13.912,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.93,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.93,47,,12.744,Percent of Total Billed Charges,47% of Total Billed Charges,15.93,47,,12.744,Percent of Total Billed Charges,47% of Total Billed Charges,15.93,30.51,
SILVADENE 1 OZ,5029080,CDM,250,RC,,,Outpatient,,,23.00,23.00,,13.51,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.51,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.13,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,10.81,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,13.51,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.81,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,20.7,
NEULASTA,5029082,CDM,250,RC,J2505,HCPCS,Outpatient,,,11244.80,11244.80,,6606.32,58.75,,185.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,6606.32,58.75,,185.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,5443.61,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,10120.32,90,,8096.256,Percent of Total Billed Charges,90% of Total Billed Charges,10120.32,90,,8096.256,Percent of Total Billed Charges,90% of Total Billed Charges,5285.06,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,10120.32,90,,8096.256,Percent of Total Billed Charges,90% of Total Billed Charges,5285.06,47,,185.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5285.06,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5285.06,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5285.06,47,,4228.048,Percent of Total Billed Charges,47% of Total Billed Charges,5285.06,47,,4228.048,Percent of Total Billed Charges,47% of Total Billed Charges,5285.06,10120.32,
TYLONOL EL WCOD12.5,5029083,CDM,259,RC,,,Outpatient,,,9.90,9.90,,5.82,58.75,,187.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.82,58.75,,187.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.79,48.41,,99.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.91,90,,7.128,Percent of Total Billed Charges,90% of Total Billed Charges,8.91,90,,7.128,Percent of Total Billed Charges,90% of Total Billed Charges,4.65,47,,96.824,Percent of Total Billed Charges,47% of Total Billed Charges,8.91,90,,7.128,Percent of Total Billed Charges,90% of Total Billed Charges,5.82,58.75,,187.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.65,47,,96.824,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.65,47,,96.824,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.65,47,,3.72,Percent of Total Billed Charges,47% of Total Billed Charges,4.65,47,,3.72,Percent of Total Billed Charges,47% of Total Billed Charges,4.65,8.91,
D5 1/2 NS 500,5029137,CDM,258,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,8.232,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,7.992,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,7.992,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,7.992,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
IV N/S 3% 500 CC,5029139,CDM,258,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,968.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,968.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,968.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
NS 3% 500,5029140,CDM,260,RC,,,Outpatient,,,16.00,16.00,,9.4,58.75,,515.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.4,58.75,,515.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.75,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.4,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,14.4,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,7.52,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,14.4,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,58.75,,515.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.52,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.52,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,7.52,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,7.52,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,7.52,150,
D10 500,5029141,CDM,260,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,21.688,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,21.056,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,21.056,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,21.056,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,150,
D5W AND NACL .225,5029143,CDM,260,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,0.928,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,0.904,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,0.904,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,0.904,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,150,
D5W 100,5029145,CDM,258,RC,,,Outpatient,,,16.75,16.75,,9.84,58.75,,226.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.84,58.75,,226.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.11,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.08,90,,12.064,Percent of Total Billed Charges,90% of Total Billed Charges,15.08,90,,12.064,Percent of Total Billed Charges,90% of Total Billed Charges,7.87,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,15.08,90,,12.064,Percent of Total Billed Charges,90% of Total Billed Charges,9.84,58.75,,226.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.87,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.87,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.87,47,,6.296,Percent of Total Billed Charges,47% of Total Billed Charges,7.87,47,,6.296,Percent of Total Billed Charges,47% of Total Billed Charges,7.87,15.08,
NS 50,5029146,CDM,258,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,1481.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,1481.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,1481.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
LORTAB ELIXIR 2.5/108MG PER5ML,5030242,CDM,259,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,1891.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,1891.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,26.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,1891.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,25.944,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
MULTITRACE-4,5030243,CDM,250,RC,,,Outpatient,,,30.00,30.00,,17.63,58.75,,56.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.63,58.75,,56.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.52,48.41,,3.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,27,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,27,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,27,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,17.63,58.75,,56.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,3.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.1,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,27,
ETOMIDATE 20 MG,5030244,CDM,250,RC,,,Outpatient,,,26.00,26.00,,15.28,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.28,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.59,48.41,,6.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,23.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,23.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,12.22,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,23.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,15.28,58.75,,26.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.22,47,,6.016,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.22,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.22,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,12.22,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,12.22,23.4,
TERBUTALINE 1 MG/ML INJ,5030245,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,3666,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,3666,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,6.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,3666,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,6.768,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
PROLASTIN C 1000 MG,5030246,CDM,250,RC,,,Outpatient,,,2251.00,2251.00,,1322.46,58.75,,1079.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,1322.46,58.75,,1079.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,1089.71,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,2025.9,90,,1620.72,Percent of Total Billed Charges,90% of Total Billed Charges,2025.9,90,,1620.72,Percent of Total Billed Charges,90% of Total Billed Charges,1057.97,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2025.9,90,,1620.72,Percent of Total Billed Charges,90% of Total Billed Charges,1322.46,58.75,,1079.12,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1057.97,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1057.97,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1057.97,47,,846.376,Percent of Total Billed Charges,47% of Total Billed Charges,1057.97,47,,846.376,Percent of Total Billed Charges,47% of Total Billed Charges,1057.97,2025.9,
CELESTONE 6 MG (BETAMETHASONE),5030247,CDM,250,RC,,,Outpatient,,,28.50,28.50,,16.74,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.74,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.8,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.65,90,,20.52,Percent of Total Billed Charges,90% of Total Billed Charges,25.65,90,,20.52,Percent of Total Billed Charges,90% of Total Billed Charges,13.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,25.65,90,,20.52,Percent of Total Billed Charges,90% of Total Billed Charges,16.74,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.4,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.4,47,,10.72,Percent of Total Billed Charges,47% of Total Billed Charges,13.4,47,,10.72,Percent of Total Billed Charges,47% of Total Billed Charges,13.4,25.65,
PREVNAR 13 PNEUMONIA VAC,5030248,CDM,250,RC,,,Outpatient,,,769.00,769.00,,451.79,58.75,,466.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,451.79,58.75,,466.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,372.27,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,692.1,90,,553.68,Percent of Total Billed Charges,90% of Total Billed Charges,692.1,90,,553.68,Percent of Total Billed Charges,90% of Total Billed Charges,361.43,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,692.1,90,,553.68,Percent of Total Billed Charges,90% of Total Billed Charges,451.79,58.75,,466.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,361.43,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,361.43,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,361.43,47,,289.144,Percent of Total Billed Charges,47% of Total Billed Charges,361.43,47,,289.144,Percent of Total Billed Charges,47% of Total Billed Charges,361.43,692.1,
CIPROFLOXACIN OPHTAL DROPS,5030249,CDM,250,RC,,,Outpatient,,,94.00,94.00,,55.23,58.75,,426.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,55.23,58.75,,426.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.51,48.41,,26.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,84.6,90,,67.68,Percent of Total Billed Charges,90% of Total Billed Charges,84.6,90,,67.68,Percent of Total Billed Charges,90% of Total Billed Charges,44.18,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,84.6,90,,67.68,Percent of Total Billed Charges,90% of Total Billed Charges,55.23,58.75,,426.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,44.18,47,,25.944,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,44.18,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,44.18,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,44.18,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,44.18,84.6,
KEPPA IV 500 MG,5030250,CDM,250,RC,,,Outpatient,,,210.00,210.00,,123.38,58.75,,845.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,123.38,58.75,,845.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,101.66,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,189,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,189,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,98.7,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,189,90,,151.2,Percent of Total Billed Charges,90% of Total Billed Charges,123.38,58.75,,845.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,98.7,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,98.7,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,98.7,47,,78.96,Percent of Total Billed Charges,47% of Total Billed Charges,98.7,47,,78.96,Percent of Total Billed Charges,47% of Total Billed Charges,98.7,189,
NEURONTIN 100 MG CAP,5030251,CDM,259,RC,,,Outpatient,,,9.00,9.00,,5.29,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.29,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.36,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.1,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,8.1,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.23,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,8.1,
LEVOPHED 4 MG INJ,5030252,CDM,250,RC,,,Outpatient,,,115.00,115.00,,67.56,58.75,,40.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,67.56,58.75,,40.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,55.67,48.41,,1.16,Percent of Total Billed Charges,48.41% of Total Billed Charges,103.5,90,,82.8,Percent of Total Billed Charges,90% of Total Billed Charges,103.5,90,,82.8,Percent of Total Billed Charges,90% of Total Billed Charges,54.05,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,103.5,90,,82.8,Percent of Total Billed Charges,90% of Total Billed Charges,67.56,58.75,,40.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,54.05,47,,1.128,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,54.05,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,54.05,47,,43.24,Percent of Total Billed Charges,47% of Total Billed Charges,54.05,47,,43.24,Percent of Total Billed Charges,47% of Total Billed Charges,54.05,103.5,
POLYSPORIN OINT 1 OZ,5030253,CDM,270,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,55.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,55.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,26.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,55.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,25.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
HYDRALAZINE 10 MG,5030254,CDM,259,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,33.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,33.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,33.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
TRABEXANIC ACID 1000MG/10ML,5030255,CDM,250,RC,,,Outpatient,,,319.00,319.00,,187.41,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,187.41,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,154.43,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,287.1,90,,229.68,Percent of Total Billed Charges,90% of Total Billed Charges,287.1,90,,229.68,Percent of Total Billed Charges,90% of Total Billed Charges,149.93,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,287.1,90,,229.68,Percent of Total Billed Charges,90% of Total Billed Charges,187.41,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,149.93,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,149.93,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,149.93,47,,119.944,Percent of Total Billed Charges,47% of Total Billed Charges,149.93,47,,119.944,Percent of Total Billed Charges,47% of Total Billed Charges,149.93,287.1,
ROCURONIUM 100 MG,5030256,CDM,250,RC,,,Outpatient,,,250.00,250.00,,146.88,58.75,,70.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,146.88,58.75,,70.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,121.03,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,225,90,,180,Percent of Total Billed Charges,90% of Total Billed Charges,225,90,,180,Percent of Total Billed Charges,90% of Total Billed Charges,117.5,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,225,90,,180,Percent of Total Billed Charges,90% of Total Billed Charges,146.88,58.75,,70.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,117.5,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,117.5,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,117.5,47,,94,Percent of Total Billed Charges,47% of Total Billed Charges,117.5,47,,94,Percent of Total Billed Charges,47% of Total Billed Charges,117.5,225,
MERREM 500 MG IV,5030257,CDM,250,RC,,,Outpatient,,,118.00,118.00,,69.33,58.75,,279.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.33,58.75,,279.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.12,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,106.2,90,,84.96,Percent of Total Billed Charges,90% of Total Billed Charges,106.2,90,,84.96,Percent of Total Billed Charges,90% of Total Billed Charges,55.46,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,106.2,90,,84.96,Percent of Total Billed Charges,90% of Total Billed Charges,69.33,58.75,,279.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.46,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,55.46,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.46,47,,44.368,Percent of Total Billed Charges,47% of Total Billed Charges,55.46,47,,44.368,Percent of Total Billed Charges,47% of Total Billed Charges,55.46,106.2,
MERREM 1 GM,5030258,CDM,250,RC,,,Outpatient,,,172.00,172.00,,101.05,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,101.05,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,83.27,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,154.8,90,,123.84,Percent of Total Billed Charges,90% of Total Billed Charges,154.8,90,,123.84,Percent of Total Billed Charges,90% of Total Billed Charges,80.84,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,154.8,90,,123.84,Percent of Total Billed Charges,90% of Total Billed Charges,101.05,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,80.84,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,80.84,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,80.84,47,,64.672,Percent of Total Billed Charges,47% of Total Billed Charges,80.84,47,,64.672,Percent of Total Billed Charges,47% of Total Billed Charges,80.84,154.8,
INVANZ 1GM,5030259,CDM,250,RC,,,Outpatient,,,510.00,510.00,,299.63,58.75,,55.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,299.63,58.75,,55.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,246.89,48.41,,37.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,459,90,,367.2,Percent of Total Billed Charges,90% of Total Billed Charges,459,90,,367.2,Percent of Total Billed Charges,90% of Total Billed Charges,239.7,47,,36.472,Percent of Total Billed Charges,47% of Total Billed Charges,459,90,,367.2,Percent of Total Billed Charges,90% of Total Billed Charges,299.63,58.75,,55.84,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,239.7,47,,36.472,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,239.7,47,,36.472,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,239.7,47,,191.76,Percent of Total Billed Charges,47% of Total Billed Charges,239.7,47,,191.76,Percent of Total Billed Charges,47% of Total Billed Charges,239.7,459,
OPTIRAY 350 100ML,5030260,CDM,259,RC,,,Outpatient,,,209.00,209.00,,122.79,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,122.79,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,101.18,48.41,,5.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,188.1,90,,150.48,Percent of Total Billed Charges,90% of Total Billed Charges,188.1,90,,150.48,Percent of Total Billed Charges,90% of Total Billed Charges,98.23,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,188.1,90,,150.48,Percent of Total Billed Charges,90% of Total Billed Charges,122.79,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,98.23,47,,5.456,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,98.23,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,98.23,47,,78.584,Percent of Total Billed Charges,47% of Total Billed Charges,98.23,47,,78.584,Percent of Total Billed Charges,47% of Total Billed Charges,98.23,188.1,
HYDRALAZINE 20 MG INJ,5030261,CDM,250,RC,,,Outpatient,,,87.00,87.00,,51.11,58.75,,4.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.11,58.75,,4.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.12,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,78.3,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,78.3,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,40.89,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,78.3,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,51.11,58.75,,4.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.89,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.89,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.89,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,40.89,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,40.89,78.3,
GENTAMYCIN OPTHAL SOL 0.3%,5030262,CDM,250,RC,,,Outpatient,,,64.00,64.00,,37.6,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.6,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.98,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,57.6,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,57.6,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,30.08,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,57.6,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,37.6,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.08,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,30.08,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.08,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,30.08,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,30.08,57.6,
OMNIPAQUE 300 100 ML,5030263,CDM,250,RC,,,Outpatient,,,395.00,395.00,,232.06,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,232.06,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,191.22,48.41,,6.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,355.5,90,,284.4,Percent of Total Billed Charges,90% of Total Billed Charges,355.5,90,,284.4,Percent of Total Billed Charges,90% of Total Billed Charges,185.65,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,355.5,90,,284.4,Percent of Total Billed Charges,90% of Total Billed Charges,232.06,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,185.65,47,,6.768,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,185.65,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,185.65,47,,148.52,Percent of Total Billed Charges,47% of Total Billed Charges,185.65,47,,148.52,Percent of Total Billed Charges,47% of Total Billed Charges,185.65,355.5,
OMNIPAQUE 350 100 ML,5030264,CDM,250,RC,,,Outpatient,,,399.00,399.00,,234.41,58.75,,93.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,234.41,58.75,,93.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,193.16,48.41,,92.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,359.1,90,,287.28,Percent of Total Billed Charges,90% of Total Billed Charges,359.1,90,,287.28,Percent of Total Billed Charges,90% of Total Billed Charges,187.53,47,,89.864,Percent of Total Billed Charges,47% of Total Billed Charges,359.1,90,,287.28,Percent of Total Billed Charges,90% of Total Billed Charges,234.41,58.75,,93.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,187.53,47,,89.864,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,187.53,47,,89.864,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,187.53,47,,150.024,Percent of Total Billed Charges,47% of Total Billed Charges,187.53,47,,150.024,Percent of Total Billed Charges,47% of Total Billed Charges,187.53,359.1,
AUGMENTIN 875 MG,5030265,CDM,259,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,26.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,26.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,26.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
REMDESIVIR 100 MG,5030266,CDM,250,RC,,,Outpatient,,,2060.00,2060.00,,1210.25,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,1210.25,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,997.25,48.41,,5.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,1854,90,,1483.2,Percent of Total Billed Charges,90% of Total Billed Charges,1854,90,,1483.2,Percent of Total Billed Charges,90% of Total Billed Charges,968.2,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,1854,90,,1483.2,Percent of Total Billed Charges,90% of Total Billed Charges,1210.25,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,968.2,47,,5.456,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,968.2,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,968.2,47,,774.56,Percent of Total Billed Charges,47% of Total Billed Charges,968.2,47,,774.56,Percent of Total Billed Charges,47% of Total Billed Charges,968.2,1854,
DAPTOMYCIN 350 MG,5030267,CDM,250,RC,,,Outpatient,,,1097.00,1097.00,,644.49,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,644.49,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,531.06,48.41,,2.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,987.3,90,,789.84,Percent of Total Billed Charges,90% of Total Billed Charges,987.3,90,,789.84,Percent of Total Billed Charges,90% of Total Billed Charges,515.59,47,,2.48,Percent of Total Billed Charges,47% of Total Billed Charges,987.3,90,,789.84,Percent of Total Billed Charges,90% of Total Billed Charges,644.49,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,515.59,47,,2.48,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,515.59,47,,2.48,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,515.59,47,,412.472,Percent of Total Billed Charges,47% of Total Billed Charges,515.59,47,,412.472,Percent of Total Billed Charges,47% of Total Billed Charges,515.59,987.3,
VIT D,5030268,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,46.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,46.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,46.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
MELATONIN 3 MG,5030269,CDM,259,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
"RETACRIT 10,000 UNITS",5030273,CDM,250,RC,,,Outpatient,,,481.00,481.00,,282.59,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,282.59,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,232.85,48.41,,9.376,Percent of Total Billed Charges,48.41% of Total Billed Charges,432.9,90,,346.32,Percent of Total Billed Charges,90% of Total Billed Charges,432.9,90,,346.32,Percent of Total Billed Charges,90% of Total Billed Charges,226.07,47,,9.096,Percent of Total Billed Charges,47% of Total Billed Charges,432.9,90,,346.32,Percent of Total Billed Charges,90% of Total Billed Charges,282.59,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,226.07,47,,9.096,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,226.07,47,,9.096,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,226.07,47,,180.856,Percent of Total Billed Charges,47% of Total Billed Charges,226.07,47,,180.856,Percent of Total Billed Charges,47% of Total Billed Charges,226.07,432.9,
FERAHEME 510 MG,5030275,CDM,250,RC,,,Outpatient,,,3152.00,3152.00,,1851.8,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,1851.8,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,1525.88,48.41,,1.704,Percent of Total Billed Charges,48.41% of Total Billed Charges,2836.8,90,,2269.44,Percent of Total Billed Charges,90% of Total Billed Charges,2836.8,90,,2269.44,Percent of Total Billed Charges,90% of Total Billed Charges,1481.44,47,,1.656,Percent of Total Billed Charges,47% of Total Billed Charges,2836.8,90,,2269.44,Percent of Total Billed Charges,90% of Total Billed Charges,1851.8,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1481.44,47,,1.656,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1481.44,47,,1.656,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1481.44,47,,1185.152,Percent of Total Billed Charges,47% of Total Billed Charges,1481.44,47,,1185.152,Percent of Total Billed Charges,47% of Total Billed Charges,1481.44,2836.8,
DALVANCE 500 MG,5030276,CDM,250,RC,,,Outpatient,,,4025.00,4025.00,,2364.69,58.75,,121.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,2364.69,58.75,,121.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,1948.5,48.41,,1.16,Percent of Total Billed Charges,48.41% of Total Billed Charges,3622.5,90,,2898,Percent of Total Billed Charges,90% of Total Billed Charges,3622.5,90,,2898,Percent of Total Billed Charges,90% of Total Billed Charges,1891.75,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,3622.5,90,,2898,Percent of Total Billed Charges,90% of Total Billed Charges,2364.69,58.75,,121.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1891.75,47,,1.128,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1891.75,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1891.75,47,,1513.4,Percent of Total Billed Charges,47% of Total Billed Charges,1891.75,47,,1513.4,Percent of Total Billed Charges,47% of Total Billed Charges,1891.75,3622.5,
CYCLOPENTOLATE 1% OPHTH SOLN,5030277,CDM,259,RC,,,Outpatient,,,120.00,120.00,,70.5,58.75,,9.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,70.5,58.75,,9.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.09,48.41,,1.16,Percent of Total Billed Charges,48.41% of Total Billed Charges,108,90,,86.4,Percent of Total Billed Charges,90% of Total Billed Charges,108,90,,86.4,Percent of Total Billed Charges,90% of Total Billed Charges,56.4,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,108,90,,86.4,Percent of Total Billed Charges,90% of Total Billed Charges,70.5,58.75,,9.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,56.4,47,,1.128,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,56.4,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,56.4,47,,45.12,Percent of Total Billed Charges,47% of Total Billed Charges,56.4,47,,45.12,Percent of Total Billed Charges,47% of Total Billed Charges,56.4,108,
CYCLOPENTOLAGE 1%,5030278,CDM,259,RC,,,Outpatient,,,57.00,57.00,,33.49,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.49,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.59,48.41,,1.16,Percent of Total Billed Charges,48.41% of Total Billed Charges,51.3,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,51.3,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,26.79,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,51.3,90,,41.04,Percent of Total Billed Charges,90% of Total Billed Charges,33.49,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,1.128,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.79,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.79,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,26.79,47,,21.432,Percent of Total Billed Charges,47% of Total Billed Charges,26.79,51.3,
LEQVIO,5030279,CDM,250,RC,,,Outpatient,,,7800.00,7800.00,,4582.5,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,4582.5,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,3775.98,48.41,,1.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,7020,90,,5616,Percent of Total Billed Charges,90% of Total Billed Charges,7020,90,,5616,Percent of Total Billed Charges,90% of Total Billed Charges,3666,47,,1.504,Percent of Total Billed Charges,47% of Total Billed Charges,7020,90,,5616,Percent of Total Billed Charges,90% of Total Billed Charges,4582.5,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3666,47,,1.504,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3666,47,,1.504,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3666,47,,2932.8,Percent of Total Billed Charges,47% of Total Billed Charges,3666,47,,2932.8,Percent of Total Billed Charges,47% of Total Billed Charges,3666,7020,
GRANIX 480 MCG,5030280,CDM,250,RC,,,Outpatient,,,2296.00,2296.00,,1348.9,58.75,,26.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,1348.9,58.75,,26.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,1111.49,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,2066.4,90,,1653.12,Percent of Total Billed Charges,90% of Total Billed Charges,2066.4,90,,1653.12,Percent of Total Billed Charges,90% of Total Billed Charges,1079.12,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,2066.4,90,,1653.12,Percent of Total Billed Charges,90% of Total Billed Charges,1348.9,58.75,,26.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1079.12,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1079.12,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1079.12,47,,863.296,Percent of Total Billed Charges,47% of Total Billed Charges,1079.12,47,,863.296,Percent of Total Billed Charges,47% of Total Billed Charges,1079.12,2066.4,
HYOSCYAMINE ELIXIR 5 ML,5030281,CDM,259,RC,,,Outpatient,,,40.00,40.00,,23.5,58.75,,1.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.5,58.75,,1.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.36,48.41,,1.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,47,,1.504,Percent of Total Billed Charges,47% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,23.5,58.75,,1.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,1.504,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.8,47,,1.504,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,36,
VERSED,5030282,CDM,250,RC,,,Outpatient,,,992.00,992.00,,582.8,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,582.8,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,480.23,48.41,,17.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,892.8,90,,714.24,Percent of Total Billed Charges,90% of Total Billed Charges,892.8,90,,714.24,Percent of Total Billed Charges,90% of Total Billed Charges,466.24,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,892.8,90,,714.24,Percent of Total Billed Charges,90% of Total Billed Charges,582.8,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,466.24,47,,16.92,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,466.24,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,466.24,47,,372.992,Percent of Total Billed Charges,47% of Total Billed Charges,466.24,47,,372.992,Percent of Total Billed Charges,47% of Total Billed Charges,466.24,892.8,
"RETACRIT 20,000 UNITS",5030283,CDM,250,RC,,,Outpatient,,,908.00,908.00,,533.45,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,533.45,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,439.56,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,817.2,90,,653.76,Percent of Total Billed Charges,90% of Total Billed Charges,817.2,90,,653.76,Percent of Total Billed Charges,90% of Total Billed Charges,426.76,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,817.2,90,,653.76,Percent of Total Billed Charges,90% of Total Billed Charges,533.45,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,426.76,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,426.76,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,426.76,47,,341.408,Percent of Total Billed Charges,47% of Total Billed Charges,426.76,47,,341.408,Percent of Total Billed Charges,47% of Total Billed Charges,426.76,817.2,
"RETACRIT 40,000 UNITS",5030284,CDM,250,RC,,,Outpatient,,,1799.00,1799.00,,1056.91,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,1056.91,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,870.9,48.41,,460.088,Percent of Total Billed Charges,48.41% of Total Billed Charges,1619.1,90,,1295.28,Percent of Total Billed Charges,90% of Total Billed Charges,1619.1,90,,1295.28,Percent of Total Billed Charges,90% of Total Billed Charges,845.53,47,,446.688,Percent of Total Billed Charges,47% of Total Billed Charges,1619.1,90,,1295.28,Percent of Total Billed Charges,90% of Total Billed Charges,1056.91,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,845.53,47,,446.688,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,845.53,47,,446.688,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,845.53,47,,676.424,Percent of Total Billed Charges,47% of Total Billed Charges,845.53,47,,676.424,Percent of Total Billed Charges,47% of Total Billed Charges,845.53,1619.1,
Morphine 4 mg Inj,5030286,CDM,250,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,35.632,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,34.592,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,34.592,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,34.592,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
Fentanyl 50 mcg,5030287,CDM,250,RC,,,Outpatient,,,87.00,87.00,,51.11,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.11,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.12,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,78.3,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,78.3,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,40.89,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,78.3,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,51.11,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.89,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.89,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.89,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,40.89,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,40.89,78.3,
Diprivan 100 mg,5030288,CDM,250,RC,,,Outpatient,,,119.00,119.00,,69.91,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.91,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.61,48.41,,19.368,Percent of Total Billed Charges,48.41% of Total Billed Charges,107.1,90,,85.68,Percent of Total Billed Charges,90% of Total Billed Charges,107.1,90,,85.68,Percent of Total Billed Charges,90% of Total Billed Charges,55.93,47,,18.8,Percent of Total Billed Charges,47% of Total Billed Charges,107.1,90,,85.68,Percent of Total Billed Charges,90% of Total Billed Charges,69.91,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.93,47,,18.8,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,55.93,47,,18.8,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.93,47,,44.744,Percent of Total Billed Charges,47% of Total Billed Charges,55.93,47,,44.744,Percent of Total Billed Charges,47% of Total Billed Charges,55.93,107.1,
Ketamine 50 mg,5030289,CDM,250,RC,,,Outpatient,,,72.00,72.00,,42.3,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.3,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.86,48.41,,1.856,Percent of Total Billed Charges,48.41% of Total Billed Charges,64.8,90,,51.84,Percent of Total Billed Charges,90% of Total Billed Charges,64.8,90,,51.84,Percent of Total Billed Charges,90% of Total Billed Charges,33.84,47,,1.808,Percent of Total Billed Charges,47% of Total Billed Charges,64.8,90,,51.84,Percent of Total Billed Charges,90% of Total Billed Charges,42.3,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.84,47,,1.808,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,33.84,47,,1.808,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.84,47,,27.072,Percent of Total Billed Charges,47% of Total Billed Charges,33.84,47,,27.072,Percent of Total Billed Charges,47% of Total Billed Charges,33.84,64.8,
Ondansetron ODT 4mg Tab,5030290,CDM,259,RC,,,Outpatient,,,75.00,75.00,,44.06,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.06,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.31,48.41,,12.008,Percent of Total Billed Charges,48.41% of Total Billed Charges,67.5,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,35.25,47,,11.656,Percent of Total Billed Charges,47% of Total Billed Charges,67.5,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,44.06,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.25,47,,11.656,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,35.25,47,,11.656,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.25,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,35.25,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,35.25,67.5,
Acetaminophen INJ,5030291,CDM,250,RC,,,Outpatient,,,150.00,150.00,,88.13,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,88.13,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,72.62,48.41,,18.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,135,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,135,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,70.5,47,,18.048,Percent of Total Billed Charges,47% of Total Billed Charges,135,90,,108,Percent of Total Billed Charges,90% of Total Billed Charges,88.13,58.75,,32.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,70.5,47,,18.048,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,70.5,47,,18.048,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,70.5,47,,56.4,Percent of Total Billed Charges,47% of Total Billed Charges,70.5,47,,56.4,Percent of Total Billed Charges,47% of Total Billed Charges,70.5,135,
Diprivan 1000 mg/100ml Drip (Propofol),5030292,CDM,250,RC,,,Outpatient,,,594.00,594.00,,348.98,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,348.98,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,287.56,48.41,,9.296,Percent of Total Billed Charges,48.41% of Total Billed Charges,534.6,90,,427.68,Percent of Total Billed Charges,90% of Total Billed Charges,534.6,90,,427.68,Percent of Total Billed Charges,90% of Total Billed Charges,279.18,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,534.6,90,,427.68,Percent of Total Billed Charges,90% of Total Billed Charges,348.98,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,279.18,47,,9.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,279.18,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,279.18,47,,223.344,Percent of Total Billed Charges,47% of Total Billed Charges,279.18,47,,223.344,Percent of Total Billed Charges,47% of Total Billed Charges,279.18,534.6,
AIRWAY NASAL,6011042,CDM,272,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
ELECTROSURG MACHINE,6011049,CDM,270,RC,,,Outpatient,,,118.80,118.80,,69.8,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,69.8,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.51,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,106.92,90,,85.536,Percent of Total Billed Charges,90% of Total Billed Charges,106.92,90,,85.536,Percent of Total Billed Charges,90% of Total Billed Charges,55.84,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,106.92,90,,85.536,Percent of Total Billed Charges,90% of Total Billed Charges,69.8,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.84,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,55.84,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,55.84,47,,44.672,Percent of Total Billed Charges,47% of Total Billed Charges,55.84,47,,44.672,Percent of Total Billed Charges,47% of Total Billed Charges,55.84,106.92,
TUBE DRN PENROSE*,6011079,CDM,270,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,31.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,31.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,39.112,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,37.976,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,31.96,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,37.976,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,37.976,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
DRAPE STERI SM,6011095,CDM,272,RC,,,Outpatient,,,9.90,9.90,,5.82,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.82,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.79,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.91,90,,7.128,Percent of Total Billed Charges,90% of Total Billed Charges,8.91,90,,7.128,Percent of Total Billed Charges,90% of Total Billed Charges,4.65,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,8.91,90,,7.128,Percent of Total Billed Charges,90% of Total Billed Charges,5.82,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.65,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.65,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.65,47,,3.72,Percent of Total Billed Charges,47% of Total Billed Charges,4.65,47,,3.72,Percent of Total Billed Charges,47% of Total Billed Charges,4.65,8.91,
DRSG IV SP DRAIN 4X4,6011102,CDM,270,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,8.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,7.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
DRESSING GAUZE KING,6011107,CDM,270,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,15.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,15.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
SIGMOIDOSCOPE/USE,6011198,CDM,272,RC,,,Outpatient,,,198.00,198.00,,116.33,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,116.33,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,95.85,48.41,,73.696,Percent of Total Billed Charges,48.41% of Total Billed Charges,178.2,90,,142.56,Percent of Total Billed Charges,90% of Total Billed Charges,178.2,90,,142.56,Percent of Total Billed Charges,90% of Total Billed Charges,93.06,47,,71.552,Percent of Total Billed Charges,47% of Total Billed Charges,178.2,90,,142.56,Percent of Total Billed Charges,90% of Total Billed Charges,116.33,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,93.06,47,,71.552,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,93.06,47,,71.552,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,93.06,47,,74.448,Percent of Total Billed Charges,47% of Total Billed Charges,93.06,47,,74.448,Percent of Total Billed Charges,47% of Total Billed Charges,93.06,178.2,
STAPLE REMOVAL SET,6011203,CDM,272,RC,,,Outpatient,,,56.00,56.00,,32.9,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.9,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.11,48.41,,30.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,50.4,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,50.4,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,26.32,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,50.4,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,32.9,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.32,47,,29.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.32,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.32,47,,21.056,Percent of Total Billed Charges,47% of Total Billed Charges,26.32,47,,21.056,Percent of Total Billed Charges,47% of Total Billed Charges,26.32,50.4,
STAPLE REMOVER,6011220,CDM,270,RC,,,Outpatient,,,24.00,24.00,,14.1,58.75,,45.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.1,58.75,,45.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.62,48.41,,40.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.6,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,21.6,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,11.28,47,,38.88,Percent of Total Billed Charges,47% of Total Billed Charges,21.6,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,58.75,,45.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,38.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.28,47,,38.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,21.6,
SUCTION STERILETUBI,6011223,CDM,270,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,6.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,6.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,48.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,47.152,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,6.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,47.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,47.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
SUCTION MACHINE,6011225,CDM,272,RC,,,Outpatient,,,99.00,99.00,,58.16,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.16,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.93,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,89.1,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,89.1,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,46.53,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,89.1,90,,71.28,Percent of Total Billed Charges,90% of Total Billed Charges,58.16,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.53,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,46.53,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.53,47,,37.224,Percent of Total Billed Charges,47% of Total Billed Charges,46.53,47,,37.224,Percent of Total Billed Charges,47% of Total Billed Charges,46.53,89.1,
DRAPE TOWEL PKG,6011264,CDM,272,RC,,,Outpatient,,,47.00,47.00,,27.61,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.61,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.75,48.41,,16.192,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,22.09,47,,15.72,Percent of Total Billed Charges,47% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,27.61,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,15.72,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,22.09,47,,15.72,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,42.3,
CHEST DRAIN TRAY DIS,6011425,CDM,272,RC,,,Outpatient,,,564.00,564.00,,331.35,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,331.35,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,273.03,48.41,,10.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,507.6,90,,406.08,Percent of Total Billed Charges,90% of Total Billed Charges,507.6,90,,406.08,Percent of Total Billed Charges,90% of Total Billed Charges,265.08,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,507.6,90,,406.08,Percent of Total Billed Charges,90% of Total Billed Charges,331.35,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,265.08,47,,10.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,265.08,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,265.08,47,,212.064,Percent of Total Billed Charges,47% of Total Billed Charges,265.08,47,,212.064,Percent of Total Billed Charges,47% of Total Billed Charges,265.08,507.6,
EQ-TOURNIQUET,6012036,CDM,272,RC,,,Outpatient,,,174.00,174.00,,102.23,58.75,,112.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,102.23,58.75,,112.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,84.23,48.41,,30.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,156.6,90,,125.28,Percent of Total Billed Charges,90% of Total Billed Charges,156.6,90,,125.28,Percent of Total Billed Charges,90% of Total Billed Charges,81.78,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,156.6,90,,125.28,Percent of Total Billed Charges,90% of Total Billed Charges,102.23,58.75,,112.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,81.78,47,,29.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,81.78,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,81.78,47,,65.424,Percent of Total Billed Charges,47% of Total Billed Charges,81.78,47,,65.424,Percent of Total Billed Charges,47% of Total Billed Charges,81.78,156.6,
TUBE ENDO*,6013009,CDM,270,RC,,,Outpatient,,,69.00,69.00,,40.54,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.54,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.4,48.41,,12.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,62.1,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,62.1,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,32.43,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,62.1,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,40.54,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.43,47,,12.408,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,32.43,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.43,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,32.43,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,32.43,62.1,
MASK DISPO,6016041,CDM,272,RC,,,Outpatient,,,37.00,37.00,,21.74,58.75,,6.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.74,58.75,,6.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.91,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,33.3,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,33.3,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,17.39,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,33.3,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,21.74,58.75,,6.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.39,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.39,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.39,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,17.39,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,17.39,33.3,
PREP TRAY DISP,6016101,CDM,272,RC,,,Outpatient,,,32.00,32.00,,18.8,58.75,,3.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,3.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,15.04,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,58.75,,3.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,28.8,
AIRWAY ORAL,6017012,CDM,272,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
"CATH, VENOUS",6017013,CDM,272,RC,,,Outpatient,,,257.50,257.50,,151.28,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,151.28,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,124.66,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,231.75,90,,185.4,Percent of Total Billed Charges,90% of Total Billed Charges,231.75,90,,185.4,Percent of Total Billed Charges,90% of Total Billed Charges,121.03,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,231.75,90,,185.4,Percent of Total Billed Charges,90% of Total Billed Charges,151.28,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,121.03,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,121.03,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,121.03,47,,96.824,Percent of Total Billed Charges,47% of Total Billed Charges,121.03,47,,96.824,Percent of Total Billed Charges,47% of Total Billed Charges,121.03,231.75,
BONE MARROW NEEDLE,6017058,CDM,272,RC,,,Outpatient,,,21.25,21.25,,12.48,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.48,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.29,48.41,,15.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.13,90,,15.304,Percent of Total Billed Charges,90% of Total Billed Charges,19.13,90,,15.304,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,47,,15.416,Percent of Total Billed Charges,47% of Total Billed Charges,19.13,90,,15.304,Percent of Total Billed Charges,90% of Total Billed Charges,12.48,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.99,47,,15.416,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.99,47,,15.416,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.99,47,,7.992,Percent of Total Billed Charges,47% of Total Billed Charges,9.99,47,,7.992,Percent of Total Billed Charges,47% of Total Billed Charges,9.99,19.13,
GLOVES SURGEON,6200045,CDM,270,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,1.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,1.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,80.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,78.208,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,1.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,78.208,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,78.208,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
AIRWAY ORAL*,6201017,CDM,270,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,11.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,11.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,11.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
DIAL A FLOW,6201021,CDM,270,RC,,,Outpatient,,,56.00,56.00,,32.9,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.9,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.11,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,50.4,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,50.4,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,26.32,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,50.4,90,,40.32,Percent of Total Billed Charges,90% of Total Billed Charges,32.9,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.32,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.32,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.32,47,,21.056,Percent of Total Billed Charges,47% of Total Billed Charges,26.32,47,,21.056,Percent of Total Billed Charges,47% of Total Billed Charges,26.32,50.4,
URINE HAT,6201031,CDM,270,RC,,,Outpatient,,,2.40,2.40,,1.41,58.75,,2.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.41,58.75,,2.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.16,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.16,90,,1.728,Percent of Total Billed Charges,90% of Total Billed Charges,2.16,90,,1.728,Percent of Total Billed Charges,90% of Total Billed Charges,1.13,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,2.16,90,,1.728,Percent of Total Billed Charges,90% of Total Billed Charges,1.41,58.75,,2.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.13,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.13,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.13,47,,0.904,Percent of Total Billed Charges,47% of Total Billed Charges,1.13,47,,0.904,Percent of Total Billed Charges,47% of Total Billed Charges,1.13,2.16,
SPONGES STERI 3X3,6201038,CDM,270,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
LEG BAG AMBL DISP,6201040,CDM,270,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,0.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,0.944,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,0.944,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,0.944,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
URINARY DRAIN BAG,6201045,CDM,270,RC,,,Outpatient,,,69.00,69.00,,40.54,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.54,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.4,48.41,,15.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,62.1,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,62.1,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,32.43,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,62.1,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,40.54,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.43,47,,15.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,32.43,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.43,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,32.43,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,32.43,62.1,
DRSNG DUODERM XTHIN,6201064,CDM,270,RC,,,Outpatient,,,9.00,9.00,,5.29,58.75,,1.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.29,58.75,,1.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.36,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.1,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.1,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,58.75,,1.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.23,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,8.1,
SITZ BATH,6201079,CDM,270,RC,,,Outpatient,,,16.00,16.00,,9.4,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.4,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.75,48.41,,18.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.4,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,14.4,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,7.52,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,14.4,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.52,47,,17.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.52,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.52,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,7.52,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,7.52,14.4,
PLAIN PKG 1/4 - 1,6201119,CDM,270,RC,,,Outpatient,,,18.00,18.00,,10.58,58.75,,1.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.58,58.75,,1.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.71,48.41,,9.296,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,8.46,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,16.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,10.58,58.75,,1.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,9.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.46,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,16.2,
FEMALE CATH KIT,6201150,CDM,270,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,21.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,21.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,36.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,21.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,35.344,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
"CONNECTOR,STRAIGHT S",6201289,CDM,270,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
"BANDAGE, TUBEGAUZE,A",6201337,CDM,270,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,558.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,558.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,24.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,558.36,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,24.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
DRESSIN PENROS 8X12,6201349,CDM,270,RC,,,Outpatient,,,69.00,69.00,,40.54,58.75,,7.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.54,58.75,,7.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.4,48.41,,14.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,62.1,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,62.1,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,32.43,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,62.1,90,,49.68,Percent of Total Billed Charges,90% of Total Billed Charges,40.54,58.75,,7.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.43,47,,14.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,32.43,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.43,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,32.43,47,,25.944,Percent of Total Billed Charges,47% of Total Billed Charges,32.43,62.1,
TRAY DRESSING 4X4,6201358,CDM,270,RC,,,Outpatient,,,12.00,12.00,,7.05,58.75,,43.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,43.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,27.496,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,43.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,26.696,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
DRSNG NON-ADHERTELF,6201359,CDM,270,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,17.04,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,16.544,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
DRSG GAUZ KLING3,6201366,CDM,270,RC,,,Outpatient,,,3.00,3.00,,1.76,58.75,,23.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.76,58.75,,23.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.45,48.41,,48.8,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,1.41,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,1.76,58.75,,23.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,47.376,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.41,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,2.7,
I V PUMP SET,6201370,CDM,270,RC,,,Outpatient,,,68.00,68.00,,39.95,58.75,,2.256,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.95,58.75,,2.256,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.92,48.41,,22.848,Percent of Total Billed Charges,48.41% of Total Billed Charges,61.2,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,61.2,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,31.96,47,,22.184,Percent of Total Billed Charges,47% of Total Billed Charges,61.2,90,,48.96,Percent of Total Billed Charges,90% of Total Billed Charges,39.95,58.75,,2.256,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.96,47,,22.184,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.96,47,,22.184,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.96,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,31.96,47,,25.568,Percent of Total Billed Charges,47% of Total Billed Charges,31.96,61.2,
KERLIX DRSNG ROLL,6201382,CDM,270,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,14.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,14.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,14.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
DRSG STERISTRIP/PD,6201398,CDM,270,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,22.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,22.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,22.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
PENROSE DRAIN,6201404,CDM,270,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
DRSNG GZ VASELINE,6201409,CDM,270,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
DRSG RE TECH 4X4,6201431,CDM,270,RC,,,Outpatient,,,12.00,12.00,,7.05,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,22.464,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,21.808,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
DEFIBILATER PADS HP,6201470,CDM,270,RC,,,Outpatient,,,97.00,97.00,,56.99,58.75,,47.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,56.99,58.75,,47.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.96,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,87.3,90,,69.84,Percent of Total Billed Charges,90% of Total Billed Charges,87.3,90,,69.84,Percent of Total Billed Charges,90% of Total Billed Charges,45.59,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,87.3,90,,69.84,Percent of Total Billed Charges,90% of Total Billed Charges,56.99,58.75,,47.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.59,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,45.59,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.59,47,,36.472,Percent of Total Billed Charges,47% of Total Billed Charges,45.59,47,,36.472,Percent of Total Billed Charges,47% of Total Billed Charges,45.59,87.3,
IRRG N.S.,6201498,CDM,270,RC,,,Outpatient,,,14.50,14.50,,8.52,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.52,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.02,48.41,,10.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.05,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,13.05,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,6.82,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,13.05,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,8.52,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.82,47,,10.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.82,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.82,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,6.82,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,6.82,13.05,
IV CATH BTFLY,6201507,CDM,270,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,24.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,23.992,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,23.992,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,23.992,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
SCALPEL #15 DISPO,6201556,CDM,270,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
ACE BANCAGE 2-3INCH,6201563,CDM,270,RC,,,Outpatient,,,18.00,18.00,,10.58,58.75,,89.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.58,58.75,,89.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.71,48.41,,11.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,8.46,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,16.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,10.58,58.75,,89.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,11.28,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.46,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,16.2,
NEEDLE BONE MARROW,6201580,CDM,270,RC,,,Outpatient,,,239.00,239.00,,140.41,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,140.41,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,115.7,48.41,,41.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,215.1,90,,172.08,Percent of Total Billed Charges,90% of Total Billed Charges,215.1,90,,172.08,Percent of Total Billed Charges,90% of Total Billed Charges,112.33,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,215.1,90,,172.08,Percent of Total Billed Charges,90% of Total Billed Charges,140.41,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,112.33,47,,39.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,112.33,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,112.33,47,,89.864,Percent of Total Billed Charges,47% of Total Billed Charges,112.33,47,,89.864,Percent of Total Billed Charges,47% of Total Billed Charges,112.33,215.1,
NEEDLE SPINAL,6201595,CDM,270,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,48.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,48.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,56.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,54.52,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,48.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,54.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,54.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
PACK COLD DISP,6201613,CDM,270,RC,Q0081,HCPCS,Outpatient,,,14.50,14.50,,8.52,58.75,,58.936,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.52,58.75,,58.936,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.02,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.05,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,13.05,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,6.82,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,13.05,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,8.52,58.75,,58.936,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.82,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.82,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.82,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,6.82,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,6.82,13.05,
ABD DRSNG PAD,6201654,CDM,270,RC,,,Outpatient,,,6.60,6.60,,3.88,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.88,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.2,48.41,,41.44,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.94,90,,4.752,Percent of Total Billed Charges,90% of Total Billed Charges,5.94,90,,4.752,Percent of Total Billed Charges,90% of Total Billed Charges,3.1,47,,40.232,Percent of Total Billed Charges,47% of Total Billed Charges,5.94,90,,4.752,Percent of Total Billed Charges,90% of Total Billed Charges,3.88,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.1,47,,40.232,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.1,47,,40.232,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.1,47,,2.48,Percent of Total Billed Charges,47% of Total Billed Charges,3.1,47,,2.48,Percent of Total Billed Charges,47% of Total Billed Charges,3.1,5.94,
SUTURES PLAIN,6201660,CDM,270,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,19.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,19.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,33.696,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,19.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,32.712,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
DRSNG EYE PAD/EA,6201664,CDM,270,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
HEEL PAD DISP,6201667,CDM,270,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,4.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,4.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
CATH PLUG,6201706,CDM,270,RC,Q0081,HCPCS,Outpatient,,,3.00,3.00,,1.76,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.76,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.45,48.41,,29.224,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,1.41,47,,28.368,Percent of Total Billed Charges,47% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,1.76,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,28.368,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.41,47,,28.368,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,2.7,
RESTRNT AN/WRSTPR,6201724,CDM,270,RC,,,Outpatient,,,2.20,2.20,,1.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.07,48.41,,27.496,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.98,90,,1.584,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,90,,1.584,Percent of Total Billed Charges,90% of Total Billed Charges,1.03,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,1.98,90,,1.584,Percent of Total Billed Charges,90% of Total Billed Charges,1.29,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.03,47,,26.696,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.03,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.03,47,,0.824,Percent of Total Billed Charges,47% of Total Billed Charges,1.03,47,,0.824,Percent of Total Billed Charges,47% of Total Billed Charges,1.03,1.98,
SUTURES ETHILONPKG,6201740,CDM,270,RC,,,Outpatient,,,24.20,24.20,,14.22,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.22,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.72,48.41,,14.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.78,90,,17.424,Percent of Total Billed Charges,90% of Total Billed Charges,21.78,90,,17.424,Percent of Total Billed Charges,90% of Total Billed Charges,11.37,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,21.78,90,,17.424,Percent of Total Billed Charges,90% of Total Billed Charges,14.22,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.37,47,,14.288,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.37,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.37,47,,9.096,Percent of Total Billed Charges,47% of Total Billed Charges,11.37,47,,9.096,Percent of Total Billed Charges,47% of Total Billed Charges,11.37,21.78,
URINE STRAINER,6201778,CDM,270,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,3.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,3.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,3.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
YANKAUER SUCTION,6201793,CDM,270,RC,,,Outpatient,,,4.40,4.40,,2.59,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.59,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.13,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,3.96,90,,3.168,Percent of Total Billed Charges,90% of Total Billed Charges,3.96,90,,3.168,Percent of Total Billed Charges,90% of Total Billed Charges,2.07,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,3.96,90,,3.168,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.07,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.07,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.07,47,,1.656,Percent of Total Billed Charges,47% of Total Billed Charges,2.07,47,,1.656,Percent of Total Billed Charges,47% of Total Billed Charges,2.07,3.96,
SWAB IODO,6201807,CDM,270,RC,,,Outpatient,,,3.00,3.00,,1.76,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.76,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.45,48.41,,24.4,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,1.41,47,,23.688,Percent of Total Billed Charges,47% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,1.76,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,23.688,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.41,47,,23.688,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,2.7,
LEMON/GLY SWABS3 PK,6201808,CDM,270,RC,,,Outpatient,,,3.00,3.00,,1.76,58.75,,19.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.76,58.75,,19.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.45,48.41,,32.144,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,1.41,47,,31.208,Percent of Total Billed Charges,47% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,1.76,58.75,,19.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,31.208,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.41,47,,31.208,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,2.7,
SYRINGE EAR/ULCER,6201809,CDM,270,RC,,,Outpatient,,,3.00,3.00,,1.76,58.75,,97.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.76,58.75,,97.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.45,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,1.41,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,1.76,58.75,,97.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.41,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,2.7,
SYRINGE ASEPTO/BLB,6201811,CDM,270,RC,,,Outpatient,,,4.00,4.00,,2.35,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.35,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.94,48.41,,23.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,3.6,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,3.6,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,1.88,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,3.6,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.88,47,,22.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.88,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.88,47,,1.504,Percent of Total Billed Charges,47% of Total Billed Charges,1.88,47,,1.504,Percent of Total Billed Charges,47% of Total Billed Charges,1.88,3.6,
SYRINGE 60CC,6201817,CDM,270,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,1.16,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,1.128,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
DRG GZ KLING 1&2 IN,6201833,CDM,270,RC,,,Outpatient,,,4.00,4.00,,2.35,58.75,,1.176,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.35,58.75,,1.176,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.94,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,3.6,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,3.6,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,1.88,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,3.6,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,58.75,,1.176,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.88,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.88,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.88,47,,1.504,Percent of Total Billed Charges,47% of Total Billed Charges,1.88,47,,1.504,Percent of Total Billed Charges,47% of Total Billed Charges,1.88,3.6,
CLAVICLE SUPPORT,6201851,CDM,270,RC,,,Outpatient,,,45.00,45.00,,26.44,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,26.44,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.78,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,40.5,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,40.5,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,26.44,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.15,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,21.15,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.15,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,21.15,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,21.15,40.5,
DRSNG ADAPTIC,6201863,CDM,270,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,15.104,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,14.664,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,14.664,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,14.664,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
RNTL CRASH CART,6201942,CDM,270,RC,,,Outpatient,,,1188.00,1188.00,,697.95,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,697.95,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,575.11,48.41,,18.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,1069.2,90,,855.36,Percent of Total Billed Charges,90% of Total Billed Charges,1069.2,90,,855.36,Percent of Total Billed Charges,90% of Total Billed Charges,558.36,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,1069.2,90,,855.36,Percent of Total Billed Charges,90% of Total Billed Charges,697.95,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,558.36,47,,17.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,558.36,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,558.36,47,,446.688,Percent of Total Billed Charges,47% of Total Billed Charges,558.36,47,,446.688,Percent of Total Billed Charges,47% of Total Billed Charges,558.36,1069.2,
COLD PAK LARGE,6202018,CDM,270,RC,,,Outpatient,,,15.40,15.40,,9.05,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.05,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.46,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.86,90,,11.088,Percent of Total Billed Charges,90% of Total Billed Charges,13.86,90,,11.088,Percent of Total Billed Charges,90% of Total Billed Charges,7.24,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,13.86,90,,11.088,Percent of Total Billed Charges,90% of Total Billed Charges,9.05,58.75,,44.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.24,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.24,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.24,47,,5.792,Percent of Total Billed Charges,47% of Total Billed Charges,7.24,47,,5.792,Percent of Total Billed Charges,47% of Total Billed Charges,7.24,13.86,
KNEE IMMBOLIZER20,6202065,CDM,270,RC,,,Outpatient,,,92.00,92.00,,54.05,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,54.05,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.54,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,82.8,90,,66.24,Percent of Total Billed Charges,90% of Total Billed Charges,82.8,90,,66.24,Percent of Total Billed Charges,90% of Total Billed Charges,43.24,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,82.8,90,,66.24,Percent of Total Billed Charges,90% of Total Billed Charges,54.05,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,43.24,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,43.24,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,43.24,47,,34.592,Percent of Total Billed Charges,47% of Total Billed Charges,43.24,47,,34.592,Percent of Total Billed Charges,47% of Total Billed Charges,43.24,82.8,
CATH SUC KIT W/WTR,6202069,CDM,270,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,30.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
Y BLOOD SET,6202089,CDM,270,RC,,,Outpatient,,,50.00,50.00,,29.38,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.38,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.21,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,45,90,,36,Percent of Total Billed Charges,90% of Total Billed Charges,45,90,,36,Percent of Total Billed Charges,90% of Total Billed Charges,23.5,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,45,90,,36,Percent of Total Billed Charges,90% of Total Billed Charges,29.38,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.5,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.5,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.5,47,,18.8,Percent of Total Billed Charges,47% of Total Billed Charges,23.5,47,,18.8,Percent of Total Billed Charges,47% of Total Billed Charges,23.5,45,
ENEMA SET,6202155,CDM,270,RC,,,Outpatient,,,4.80,4.80,,2.82,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.82,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.32,48.41,,14.056,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.32,90,,3.456,Percent of Total Billed Charges,90% of Total Billed Charges,4.32,90,,3.456,Percent of Total Billed Charges,90% of Total Billed Charges,2.26,47,,13.648,Percent of Total Billed Charges,47% of Total Billed Charges,4.32,90,,3.456,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.26,47,,13.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.26,47,,13.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.26,47,,1.808,Percent of Total Billed Charges,47% of Total Billed Charges,2.26,47,,1.808,Percent of Total Billed Charges,47% of Total Billed Charges,2.26,4.32,
TRAY CATH W/FOLEY,6202207,CDM,270,RC,,,Outpatient,,,31.00,31.00,,18.21,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.21,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.01,48.41,,87.912,Percent of Total Billed Charges,48.41% of Total Billed Charges,27.9,90,,22.32,Percent of Total Billed Charges,90% of Total Billed Charges,27.9,90,,22.32,Percent of Total Billed Charges,90% of Total Billed Charges,14.57,47,,85.352,Percent of Total Billed Charges,47% of Total Billed Charges,27.9,90,,22.32,Percent of Total Billed Charges,90% of Total Billed Charges,18.21,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.57,47,,85.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.57,47,,85.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.57,47,,11.656,Percent of Total Billed Charges,47% of Total Billed Charges,14.57,47,,11.656,Percent of Total Billed Charges,47% of Total Billed Charges,14.57,27.9,
TRAY IRRIGATION,6202229,CDM,270,RC,,,Outpatient,,,48.00,48.00,,28.2,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.2,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.24,48.41,,29.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,43.2,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,43.2,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,22.56,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,43.2,90,,34.56,Percent of Total Billed Charges,90% of Total Billed Charges,28.2,58.75,,59.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.56,47,,28.2,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,22.56,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.56,47,,18.048,Percent of Total Billed Charges,47% of Total Billed Charges,22.56,47,,18.048,Percent of Total Billed Charges,47% of Total Billed Charges,22.56,43.2,
TRAY PREP SHAVE,6202264,CDM,270,RC,,,Outpatient,,,24.00,24.00,,14.1,58.75,,27.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.1,58.75,,27.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.62,48.41,,174.28,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.6,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,21.6,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,11.28,47,,169.2,Percent of Total Billed Charges,47% of Total Billed Charges,21.6,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,58.75,,27.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,169.2,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.28,47,,169.2,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,21.6,
TRAY CATH W/O FOLY,6202276,CDM,270,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,107.28,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,104.152,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,104.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,104.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
SUTURE REMOVAL TRAY,6202278,CDM,270,RC,,,Outpatient,,,28.00,28.00,,16.45,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,17.04,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,16.544,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,25.2,
TRAY SUTURE,6202279,CDM,270,RC,,,Outpatient,,,101.00,101.00,,59.34,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,59.34,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.89,48.41,,41.44,Percent of Total Billed Charges,48.41% of Total Billed Charges,90.9,90,,72.72,Percent of Total Billed Charges,90% of Total Billed Charges,90.9,90,,72.72,Percent of Total Billed Charges,90% of Total Billed Charges,47.47,47,,40.232,Percent of Total Billed Charges,47% of Total Billed Charges,90.9,90,,72.72,Percent of Total Billed Charges,90% of Total Billed Charges,59.34,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47.47,47,,40.232,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47.47,47,,40.232,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47.47,47,,37.976,Percent of Total Billed Charges,47% of Total Billed Charges,47.47,47,,37.976,Percent of Total Billed Charges,47% of Total Billed Charges,47.47,90.9,
TRAY TRACH CARE,6202288,CDM,270,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
PRIMARY IV TUBING,6202335,CDM,270,RC,,,Outpatient,,,20.90,20.90,,12.28,58.75,,27.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.28,58.75,,27.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.12,48.41,,41.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,9.82,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,12.28,58.75,,27.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,39.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.82,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,18.81,
IV EXTENSION SET,6202337,CDM,270,RC,,,Outpatient,,,40.00,40.00,,23.5,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.5,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.36,48.41,,17.04,Percent of Total Billed Charges,48.41% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,23.5,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,16.544,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.8,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,36,
EQ-GASTROSCOPE,6203033,CDM,272,RC,,,Outpatient,,,190.30,190.30,,111.8,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,111.8,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,92.12,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,171.27,90,,137.016,Percent of Total Billed Charges,90% of Total Billed Charges,171.27,90,,137.016,Percent of Total Billed Charges,90% of Total Billed Charges,89.44,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,171.27,90,,137.016,Percent of Total Billed Charges,90% of Total Billed Charges,111.8,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,89.44,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,89.44,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,89.44,47,,71.552,Percent of Total Billed Charges,47% of Total Billed Charges,89.44,47,,71.552,Percent of Total Billed Charges,47% of Total Billed Charges,89.44,171.27,
CATH COUDE 5CC,6203137,CDM,270,RC,,,Outpatient,,,79.00,79.00,,46.41,58.75,,29.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.41,58.75,,29.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.24,48.41,,9.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,71.1,90,,56.88,Percent of Total Billed Charges,90% of Total Billed Charges,71.1,90,,56.88,Percent of Total Billed Charges,90% of Total Billed Charges,37.13,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,71.1,90,,56.88,Percent of Total Billed Charges,90% of Total Billed Charges,46.41,58.75,,29.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.13,47,,9.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,37.13,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.13,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,37.13,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,37.13,71.1,
EQ-LIGHT SOURCE,6203156,CDM,272,RC,,,Outpatient,,,103.40,103.40,,60.75,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,60.75,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.06,48.41,,99.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,93.06,90,,74.448,Percent of Total Billed Charges,90% of Total Billed Charges,93.06,90,,74.448,Percent of Total Billed Charges,90% of Total Billed Charges,48.6,47,,96.824,Percent of Total Billed Charges,47% of Total Billed Charges,93.06,90,,74.448,Percent of Total Billed Charges,90% of Total Billed Charges,60.75,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.6,47,,96.824,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,48.6,47,,96.824,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.6,47,,38.88,Percent of Total Billed Charges,47% of Total Billed Charges,48.6,47,,38.88,Percent of Total Billed Charges,47% of Total Billed Charges,48.6,93.06,
EQ-COLONOSCOPE,6203214,CDM,272,RC,,,Outpatient,,,125.40,125.40,,73.67,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.67,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,60.71,48.41,,5.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,112.86,90,,90.288,Percent of Total Billed Charges,90% of Total Billed Charges,112.86,90,,90.288,Percent of Total Billed Charges,90% of Total Billed Charges,58.94,47,,5,Percent of Total Billed Charges,47% of Total Billed Charges,112.86,90,,90.288,Percent of Total Billed Charges,90% of Total Billed Charges,73.67,58.75,,14.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,58.94,47,,5,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,58.94,47,,5,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,58.94,47,,47.152,Percent of Total Billed Charges,47% of Total Billed Charges,58.94,47,,47.152,Percent of Total Billed Charges,47% of Total Billed Charges,58.94,112.86,
MALE CATH KIT,6205041,CDM,270,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,68.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,68.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,18.976,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,18.424,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,68.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,18.424,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,18.424,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
CATH FOLEY TEF,6205086,CDM,270,RC,,,Outpatient,,,41.80,41.80,,24.56,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.56,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.24,48.41,,18.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,37.62,90,,30.096,Percent of Total Billed Charges,90% of Total Billed Charges,37.62,90,,30.096,Percent of Total Billed Charges,90% of Total Billed Charges,19.65,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,37.62,90,,30.096,Percent of Total Billed Charges,90% of Total Billed Charges,24.56,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.65,47,,17.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,19.65,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.65,47,,15.72,Percent of Total Billed Charges,47% of Total Billed Charges,19.65,47,,15.72,Percent of Total Billed Charges,47% of Total Billed Charges,19.65,37.62,
CATH FOLEY TEF,6205113,CDM,270,RC,,,Outpatient,,,27.00,27.00,,15.86,58.75,,50.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.86,58.75,,50.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.07,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,24.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,24.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,12.69,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,24.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,15.86,58.75,,50.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.69,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,24.3,
CATH 30CC,6205132,CDM,270,RC,,,Outpatient,,,79.00,79.00,,46.41,58.75,,40.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.41,58.75,,40.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.24,48.41,,19.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,71.1,90,,56.88,Percent of Total Billed Charges,90% of Total Billed Charges,71.1,90,,56.88,Percent of Total Billed Charges,90% of Total Billed Charges,37.13,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,71.1,90,,56.88,Percent of Total Billed Charges,90% of Total Billed Charges,46.41,58.75,,40.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.13,47,,19.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,37.13,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.13,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,37.13,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,37.13,71.1,
CATH SUCTION,6205152,CDM,270,RC,,,Outpatient,,,33.00,33.00,,19.39,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.39,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.98,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,29.7,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,29.7,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,15.51,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,29.7,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,19.39,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.51,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,29.7,
ELECTRODE EA,6205221,CDM,270,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,5.64,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
TUBE CONNECTING*,6205254,CDM,270,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,35.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,35.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,35.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
ACE BANDAGE 6,6205263,CDM,270,RC,,,Outpatient,,,7.70,7.70,,4.52,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.52,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.73,48.41,,17.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.93,90,,5.544,Percent of Total Billed Charges,90% of Total Billed Charges,6.93,90,,5.544,Percent of Total Billed Charges,90% of Total Billed Charges,3.62,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,6.93,90,,5.544,Percent of Total Billed Charges,90% of Total Billed Charges,4.52,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.62,47,,16.92,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.62,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.62,47,,2.896,Percent of Total Billed Charges,47% of Total Billed Charges,3.62,47,,2.896,Percent of Total Billed Charges,47% of Total Billed Charges,3.62,6.93,
CORD CLAMPS,6205272,CDM,270,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,17.04,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,17.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,16.544,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
RECTAL TUBE,6205280,CDM,270,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
SALEM SUMP TUBE,6205284,CDM,270,RC,,,Outpatient,,,41.00,41.00,,24.09,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.09,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.85,48.41,,4.264,Percent of Total Billed Charges,48.41% of Total Billed Charges,36.9,90,,29.52,Percent of Total Billed Charges,90% of Total Billed Charges,36.9,90,,29.52,Percent of Total Billed Charges,90% of Total Billed Charges,19.27,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,36.9,90,,29.52,Percent of Total Billed Charges,90% of Total Billed Charges,24.09,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.27,47,,4.136,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,19.27,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,19.27,47,,15.416,Percent of Total Billed Charges,47% of Total Billed Charges,19.27,47,,15.416,Percent of Total Billed Charges,47% of Total Billed Charges,19.27,36.9,
TUBE TRACH DISP,6205288,CDM,270,RC,,,Outpatient,,,208.00,208.00,,122.2,58.75,,29.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,122.2,58.75,,29.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,100.69,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,187.2,90,,149.76,Percent of Total Billed Charges,90% of Total Billed Charges,187.2,90,,149.76,Percent of Total Billed Charges,90% of Total Billed Charges,97.76,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,187.2,90,,149.76,Percent of Total Billed Charges,90% of Total Billed Charges,122.2,58.75,,29.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,97.76,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,97.76,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,97.76,47,,78.208,Percent of Total Billed Charges,47% of Total Billed Charges,97.76,47,,78.208,Percent of Total Billed Charges,47% of Total Billed Charges,97.76,187.2,
ACE BANDAGE 4,6205291,CDM,270,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,39.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,39.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,39.008,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
IV SECONDARY SET,6205297,CDM,270,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,14.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,13.912,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
CASTILE SOAP,6205307,CDM,270,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,41.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,39.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
TUBE STOMACH LEVIN,6205399,CDM,270,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
ARMBOARD,6205408,CDM,270,RC,,,Outpatient,,,2.50,2.50,,1.47,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.47,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.21,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.25,90,,1.8,Percent of Total Billed Charges,90% of Total Billed Charges,2.25,90,,1.8,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,2.25,90,,1.8,Percent of Total Billed Charges,90% of Total Billed Charges,1.47,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.18,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.18,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.18,47,,0.944,Percent of Total Billed Charges,47% of Total Billed Charges,1.18,47,,0.944,Percent of Total Billed Charges,47% of Total Billed Charges,1.18,2.25,
ARM SLING CHILD,6206200,CDM,270,RC,,,Outpatient,,,40.00,40.00,,23.5,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.5,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.36,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,23.5,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.8,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,36,
COLOSTOMY POUCH,6207059,CDM,270,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,63.512,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,61.664,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,61.664,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,61.664,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
RIB BELT MAL/FEM,6208002,CDM,270,RC,,,Outpatient,,,47.00,47.00,,27.61,58.75,,69.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.61,58.75,,69.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.75,48.41,,3.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,22.09,47,,3.312,Percent of Total Billed Charges,47% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,27.61,58.75,,69.656,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,3.312,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,22.09,47,,3.312,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,42.3,
CATH RED RUBBER,6208028,CDM,270,RC,,,Outpatient,,,24.00,24.00,,14.1,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.1,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.62,48.41,,1.16,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.6,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,21.6,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,11.28,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,21.6,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,1.128,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.28,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,21.6,
CAST BOOT,6208041,CDM,270,RC,,,Outpatient,,,94.00,94.00,,55.23,58.75,,18.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,55.23,58.75,,18.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.51,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,84.6,90,,67.68,Percent of Total Billed Charges,90% of Total Billed Charges,84.6,90,,67.68,Percent of Total Billed Charges,90% of Total Billed Charges,44.18,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,84.6,90,,67.68,Percent of Total Billed Charges,90% of Total Billed Charges,55.23,58.75,,18.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,44.18,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,44.18,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,44.18,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,44.18,47,,35.344,Percent of Total Billed Charges,47% of Total Billed Charges,44.18,84.6,
CERV COLLAR ADUUNIV,6208043,CDM,270,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
CERVICAL COLLARCHIL,6208044,CDM,270,RC,,,Outpatient,,,64.00,64.00,,37.6,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.6,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.98,48.41,,25.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,57.6,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,57.6,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,30.08,47,,24.4,Percent of Total Billed Charges,47% of Total Billed Charges,57.6,90,,46.08,Percent of Total Billed Charges,90% of Total Billed Charges,37.6,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.08,47,,24.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,30.08,47,,24.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.08,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,30.08,47,,24.064,Percent of Total Billed Charges,47% of Total Billed Charges,30.08,57.6,
CATH 5CC,6208046,CDM,270,RC,,,Outpatient,,,38.00,38.00,,22.33,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.33,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.4,48.41,,12.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,34.2,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,34.2,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,34.2,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,22.33,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,12.408,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.86,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,34.2,
CERVICAL COLLAR,6208053,CDM,270,RC,,,Outpatient,,,71.00,71.00,,41.71,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.71,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.37,48.41,,35.632,Percent of Total Billed Charges,48.41% of Total Billed Charges,63.9,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,63.9,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,33.37,47,,34.592,Percent of Total Billed Charges,47% of Total Billed Charges,63.9,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,41.71,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.37,47,,34.592,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,33.37,47,,34.592,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.37,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,33.37,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,33.37,63.9,
CRUTCHES TALL ADU-PR,6208061,CDM,270,RC,,,Outpatient,,,44.00,44.00,,25.85,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.85,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.3,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,20.68,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,25.85,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,20.68,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,20.68,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,20.68,39.6,
KNEE IMMOBILIZER 16,6208069,CDM,270,RC,,,Outpatient,,,126.00,126.00,,74.03,58.75,,17.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,74.03,58.75,,17.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,61,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,113.4,90,,90.72,Percent of Total Billed Charges,90% of Total Billed Charges,113.4,90,,90.72,Percent of Total Billed Charges,90% of Total Billed Charges,59.22,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,113.4,90,,90.72,Percent of Total Billed Charges,90% of Total Billed Charges,74.03,58.75,,17.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,59.22,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,59.22,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,59.22,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,59.22,47,,47.376,Percent of Total Billed Charges,47% of Total Billed Charges,59.22,113.4,
SHOULDER IMMB,6208071,CDM,270,RC,,,Outpatient,,,59.00,59.00,,34.66,58.75,,106.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.66,58.75,,106.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.56,48.41,,98.368,Percent of Total Billed Charges,48.41% of Total Billed Charges,53.1,90,,42.48,Percent of Total Billed Charges,90% of Total Billed Charges,53.1,90,,42.48,Percent of Total Billed Charges,90% of Total Billed Charges,27.73,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,53.1,90,,42.48,Percent of Total Billed Charges,90% of Total Billed Charges,34.66,58.75,,106.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.73,47,,95.504,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,27.73,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.73,47,,22.184,Percent of Total Billed Charges,47% of Total Billed Charges,27.73,47,,22.184,Percent of Total Billed Charges,47% of Total Billed Charges,27.73,53.1,
"PLASTER,OCL3 WPER",6208077,CDM,270,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,7.24,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,7.032,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,35.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,7.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,7.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
"PLASTER,OCL4 WPER",6208078,CDM,270,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,211.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,211.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,12.352,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,11.992,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,211.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,11.992,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,11.992,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
"PLASTER,OCL5 WPER",6208079,CDM,270,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,130.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,130.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,73.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,71.816,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,130.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,71.816,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,71.816,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
"PLASTER,OCL6 WPER",6208080,CDM,270,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
CAST SHOE,6208082,CDM,270,RC,,,Outpatient,,,58.00,58.00,,34.08,58.75,,50.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.08,58.75,,50.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.08,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,52.2,90,,41.76,Percent of Total Billed Charges,90% of Total Billed Charges,52.2,90,,41.76,Percent of Total Billed Charges,90% of Total Billed Charges,27.26,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,52.2,90,,41.76,Percent of Total Billed Charges,90% of Total Billed Charges,34.08,58.75,,50.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.26,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,27.26,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.26,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,27.26,47,,21.808,Percent of Total Billed Charges,47% of Total Billed Charges,27.26,52.2,
ARM SLING ADULT,6208084,CDM,270,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
SPLINT FGR ALUM/PAD,6208116,CDM,270,RC,,,Outpatient,,,27.00,27.00,,15.86,58.75,,49.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.86,58.75,,49.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.07,48.41,,9.296,Percent of Total Billed Charges,48.41% of Total Billed Charges,24.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,24.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,12.69,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,24.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,15.86,58.75,,49.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,9.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.69,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,24.3,
"SPLINT MET WRS,FRARM",6208117,CDM,270,RC,,,Outpatient,,,63.80,63.80,,37.48,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.48,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.89,48.41,,10.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,57.42,90,,45.936,Percent of Total Billed Charges,90% of Total Billed Charges,57.42,90,,45.936,Percent of Total Billed Charges,90% of Total Billed Charges,29.99,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,57.42,90,,45.936,Percent of Total Billed Charges,90% of Total Billed Charges,37.48,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.99,47,,10.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,29.99,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.99,47,,23.992,Percent of Total Billed Charges,47% of Total Billed Charges,29.99,47,,23.992,Percent of Total Billed Charges,47% of Total Billed Charges,29.99,57.42,
SPLINT FINGER/FOAM,6208157,CDM,270,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,8.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,8.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
SPLNT WRST/FOREARM,6208162,CDM,270,RC,,,Outpatient,,,30.00,30.00,,17.63,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.63,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.52,48.41,,8.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,27,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,27,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,27,90,,21.6,Percent of Total Billed Charges,90% of Total Billed Charges,17.63,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,8.648,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.1,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.1,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,47,,11.28,Percent of Total Billed Charges,47% of Total Billed Charges,14.1,27,
LUMBO-SACR SUPPORT,6208179,CDM,270,RC,,,Outpatient,,,106.00,106.00,,62.28,58.75,,121.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.28,58.75,,121.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.31,48.41,,13.944,Percent of Total Billed Charges,48.41% of Total Billed Charges,95.4,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,95.4,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,49.82,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,95.4,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,62.28,58.75,,121.024,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.82,47,,13.536,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,49.82,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.82,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,49.82,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,49.82,95.4,
BACK SUPPORT,6208209,CDM,270,RC,,,Outpatient,,,145.00,145.00,,85.19,58.75,,6.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,85.19,58.75,,6.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,70.19,48.41,,201.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,130.5,90,,104.4,Percent of Total Billed Charges,90% of Total Billed Charges,130.5,90,,104.4,Percent of Total Billed Charges,90% of Total Billed Charges,68.15,47,,195.896,Percent of Total Billed Charges,47% of Total Billed Charges,130.5,90,,104.4,Percent of Total Billed Charges,90% of Total Billed Charges,85.19,58.75,,6.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,68.15,47,,195.896,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,68.15,47,,195.896,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,68.15,47,,54.52,Percent of Total Billed Charges,47% of Total Billed Charges,68.15,47,,54.52,Percent of Total Billed Charges,47% of Total Billed Charges,68.15,130.5,
SPLINT FINGER/FROG,6208264,CDM,270,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,3.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,3.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
SPLINT;ANKLE,6208298,CDM,270,RC,,,Outpatient,,,107.00,107.00,,62.86,58.75,,23.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.86,58.75,,23.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.8,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,96.3,90,,77.04,Percent of Total Billed Charges,90% of Total Billed Charges,96.3,90,,77.04,Percent of Total Billed Charges,90% of Total Billed Charges,50.29,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,96.3,90,,77.04,Percent of Total Billed Charges,90% of Total Billed Charges,62.86,58.75,,23.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,50.29,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,50.29,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,50.29,47,,40.232,Percent of Total Billed Charges,47% of Total Billed Charges,50.29,47,,40.232,Percent of Total Billed Charges,47% of Total Billed Charges,50.29,96.3,
1/2 LEG AIR SPLINT,6208301,CDM,270,RC,,,Outpatient,,,87.00,87.00,,51.11,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.11,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.12,48.41,,24.4,Percent of Total Billed Charges,48.41% of Total Billed Charges,78.3,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,78.3,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,40.89,47,,23.688,Percent of Total Billed Charges,47% of Total Billed Charges,78.3,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,51.11,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.89,47,,23.688,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.89,47,,23.688,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.89,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,40.89,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,40.89,78.3,
FEEDING SET,6208304,CDM,270,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
ISOCAL HN,6208305,CDM,259,RC,,,Outpatient,,,12.00,12.00,,7.05,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.05,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.81,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,5.64,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,10.8,90,,8.64,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.64,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.64,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,47,,4.512,Percent of Total Billed Charges,47% of Total Billed Charges,5.64,10.8,
KNEE SLEEVE,6208314,CDM,270,RC,,,Outpatient,,,75.45,75.45,,44.33,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.33,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.53,48.41,,6.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,67.91,90,,54.328,Percent of Total Billed Charges,90% of Total Billed Charges,67.91,90,,54.328,Percent of Total Billed Charges,90% of Total Billed Charges,35.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,67.91,90,,54.328,Percent of Total Billed Charges,90% of Total Billed Charges,44.33,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,35.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.46,47,,28.368,Percent of Total Billed Charges,47% of Total Billed Charges,35.46,47,,28.368,Percent of Total Billed Charges,47% of Total Billed Charges,35.46,67.91,
FEEDING BAG (PUMP),6208315,CDM,270,RC,,,Outpatient,,,71.00,71.00,,41.71,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.71,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.37,48.41,,22.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,63.9,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,63.9,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,33.37,47,,22,Percent of Total Billed Charges,47% of Total Billed Charges,63.9,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,41.71,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.37,47,,22,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,33.37,47,,22,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.37,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,33.37,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,33.37,63.9,
CPR MICRO/SHIELD,6208318,CDM,270,RC,,,Outpatient,,,38.00,38.00,,22.33,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.33,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.4,48.41,,3.024,Percent of Total Billed Charges,48.41% of Total Billed Charges,34.2,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,34.2,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,17.86,47,,2.936,Percent of Total Billed Charges,47% of Total Billed Charges,34.2,90,,27.36,Percent of Total Billed Charges,90% of Total Billed Charges,22.33,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,2.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.86,47,,2.936,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.86,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,47,,14.288,Percent of Total Billed Charges,47% of Total Billed Charges,17.86,34.2,
MULTI DRESSING,6208322,CDM,270,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,21.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,21.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,21.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
TRI BANDAGE,6208324,CDM,270,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,2.112,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,2.048,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,2.048,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,2.048,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
LRG DUODERM,6208383,CDM,272,RC,,,Outpatient,,,63.00,63.00,,37.01,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.01,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.5,48.41,,30.592,Percent of Total Billed Charges,48.41% of Total Billed Charges,56.7,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,56.7,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,29.61,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,56.7,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,37.01,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.61,47,,29.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,29.61,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.61,47,,23.688,Percent of Total Billed Charges,47% of Total Billed Charges,29.61,47,,23.688,Percent of Total Billed Charges,47% of Total Billed Charges,29.61,56.7,
18FR CATH TRY W/URO,6208384,CDM,270,RC,,,Outpatient,,,83.00,83.00,,48.76,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.76,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.18,48.41,,76.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,74.7,90,,59.76,Percent of Total Billed Charges,90% of Total Billed Charges,74.7,90,,59.76,Percent of Total Billed Charges,90% of Total Billed Charges,39.01,47,,74.448,Percent of Total Billed Charges,47% of Total Billed Charges,74.7,90,,59.76,Percent of Total Billed Charges,90% of Total Billed Charges,48.76,58.75,,5.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,39.01,47,,74.448,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,39.01,47,,74.448,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,39.01,47,,31.208,Percent of Total Billed Charges,47% of Total Billed Charges,39.01,47,,31.208,Percent of Total Billed Charges,47% of Total Billed Charges,39.01,74.7,
Peri Wash Spray 8 oz.,6208385,CDM,270,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,183.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,178.224,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,178.224,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,178.224,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
14F & 16F COUDECATH,6208387,CDM,270,RC,,,Outpatient,,,61.00,61.00,,35.84,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.84,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.53,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,54.9,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,28.67,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,54.9,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,35.84,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.67,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,54.9,
HOT/COLD PAK,6208392,CDM,270,RC,,,Outpatient,,,3.00,3.00,,1.76,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.76,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.45,48.41,,16.848,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,1.41,47,,16.36,Percent of Total Billed Charges,47% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,1.76,58.75,,17.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,16.36,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.41,47,,16.36,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,2.7,
STERI STRIPS 1/8X3,6208394,CDM,270,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,49.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,49.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,24.4,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,23.688,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,49.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,23.688,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,23.688,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
FINGER/THUMB SPLINT,6208395,CDM,270,RC,,,Outpatient,,,27.00,27.00,,15.86,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.86,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.07,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,24.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,24.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,12.69,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,24.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,15.86,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.69,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,24.3,
3 WAY STOPCOCK,6208403,CDM,270,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,18.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,17.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
THORACENTESIS TRAY,6208405,CDM,270,RC,,,Outpatient,,,148.20,148.20,,87.07,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,87.07,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,71.74,48.41,,49.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,133.38,90,,106.704,Percent of Total Billed Charges,90% of Total Billed Charges,133.38,90,,106.704,Percent of Total Billed Charges,90% of Total Billed Charges,69.65,47,,48.128,Percent of Total Billed Charges,47% of Total Billed Charges,133.38,90,,106.704,Percent of Total Billed Charges,90% of Total Billed Charges,87.07,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,69.65,47,,48.128,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,69.65,47,,48.128,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,69.65,47,,55.72,Percent of Total Billed Charges,47% of Total Billed Charges,69.65,47,,55.72,Percent of Total Billed Charges,47% of Total Billed Charges,69.65,133.38,
5-N-1 CONNECTOR,6208407,CDM,270,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,77.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,77.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,1.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,1.504,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,77.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,1.504,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,1.504,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
K-MODULE HEATING PAD,6208412,CDM,270,RC,,,Outpatient,,,39.00,39.00,,22.91,58.75,,4.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.91,58.75,,4.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.88,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,35.1,90,,28.08,Percent of Total Billed Charges,90% of Total Billed Charges,35.1,90,,28.08,Percent of Total Billed Charges,90% of Total Billed Charges,18.33,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,35.1,90,,28.08,Percent of Total Billed Charges,90% of Total Billed Charges,22.91,58.75,,4.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.33,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.33,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.33,47,,14.664,Percent of Total Billed Charges,47% of Total Billed Charges,18.33,47,,14.664,Percent of Total Billed Charges,47% of Total Billed Charges,18.33,35.1,
NITRO MICRODRIPIV,6208415,CDM,270,RC,,,Outpatient,,,47.00,47.00,,27.61,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.61,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.75,48.41,,12.392,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,22.09,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,27.61,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,12.032,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,22.09,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,42.3,
STERI STRIP 1/2X 4,6208419,CDM,270,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,10.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,10.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
STERI STRIP 1/4X3,6208420,CDM,270,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,12.784,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,12.408,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
SPONGES OPTIPORE,6208422,CDM,270,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,30.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,30.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,15.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,30.504,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,15.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
SHUR-CLENS 20ML,6208423,CDM,270,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,6.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,6.768,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
HUBER NEEDLE,6208427,CDM,270,RC,,,Outpatient,,,36.30,36.30,,21.33,58.75,,43.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.33,58.75,,43.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.57,48.41,,20.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,32.67,90,,26.136,Percent of Total Billed Charges,90% of Total Billed Charges,32.67,90,,26.136,Percent of Total Billed Charges,90% of Total Billed Charges,17.06,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,32.67,90,,26.136,Percent of Total Billed Charges,90% of Total Billed Charges,21.33,58.75,,43.24,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.06,47,,19.552,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.06,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.06,47,,13.648,Percent of Total Billed Charges,47% of Total Billed Charges,17.06,47,,13.648,Percent of Total Billed Charges,47% of Total Billed Charges,17.06,32.67,
STAPLER/SKIN DISP,6208432,CDM,270,RC,,,Outpatient,,,227.00,227.00,,133.36,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,133.36,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,109.89,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,204.3,90,,163.44,Percent of Total Billed Charges,90% of Total Billed Charges,204.3,90,,163.44,Percent of Total Billed Charges,90% of Total Billed Charges,106.69,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,204.3,90,,163.44,Percent of Total Billed Charges,90% of Total Billed Charges,133.36,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,106.69,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,106.69,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,106.69,47,,85.352,Percent of Total Billed Charges,47% of Total Billed Charges,106.69,47,,85.352,Percent of Total Billed Charges,47% of Total Billed Charges,106.69,204.3,
ANKLE SUPPORT,6208434,CDM,270,RC,,,Outpatient,,,75.00,75.00,,44.06,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.06,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.31,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,67.5,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,67.5,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,35.25,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,67.5,90,,54,Percent of Total Billed Charges,90% of Total Billed Charges,44.06,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.25,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,35.25,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.25,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,35.25,47,,28.2,Percent of Total Billed Charges,47% of Total Billed Charges,35.25,67.5,
TRAY PEG PLACEMENT,6208437,CDM,360,RC,43246,HCPCS,Outpatient,,,450.00,450.00,,264.38,58.75,,119.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,264.38,58.75,,119.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,217.85,48.41,,53.832,Percent of Total Billed Charges,48.41% of Total Billed Charges,1702.4,100,,,fee Schedule,100% of ASC Tier Groupings ,1702.4,100,,,Fee Schedule,100% of ASC Tier Groupings,211.5,47,,52.264,Percent of Total Billed Charges,47% of Total Billed Charges,1702.4,100,,,Fee Schedule,100% of ASC Tier Groupings,264.38,58.75,,119.384,Percent of Total Billed Charges,58.75% of Total Billed Charges,574.53,100,,,Fee Schedule,100% of ASC Tier Groupings,211.5,47,,52.264,Percent of Total Billed Charges,47% of Total Billed charges,574.53,100,,,Fee Schedule,100% ASC Tier Groupings,211.5,47,,52.264,Percent of Total Billed Charges,47% of Total Billed Charges,620,100,,,Fee Schedule,100% of ASC Tier Groupings,201.56,115,,,Fee Schedule,115% of CMS OPPS Rate,201.56,115,,,Fee Schedule,115% of CMS OPPS Rate,201.56,1702.4,
METAL POST. TIB/FIBU,6208438,CDM,270,RC,,,Outpatient,,,277.00,277.00,,162.74,58.75,,8.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,162.74,58.75,,8.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,134.1,48.41,,27.496,Percent of Total Billed Charges,48.41% of Total Billed Charges,249.3,90,,199.44,Percent of Total Billed Charges,90% of Total Billed Charges,249.3,90,,199.44,Percent of Total Billed Charges,90% of Total Billed Charges,130.19,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,249.3,90,,199.44,Percent of Total Billed Charges,90% of Total Billed Charges,162.74,58.75,,8.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,130.19,47,,26.696,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,130.19,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,130.19,47,,104.152,Percent of Total Billed Charges,47% of Total Billed Charges,130.19,47,,104.152,Percent of Total Billed Charges,47% of Total Billed Charges,130.19,249.3,
ELECTRODES,6208439,CDM,270,RC,,,Outpatient,,,44.00,44.00,,25.85,58.75,,14.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.85,58.75,,14.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.3,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,20.68,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,25.85,58.75,,14.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,20.68,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,20.68,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,20.68,39.6,
SHOULDER PULLY,6208443,CDM,270,RC,99070,HCPCS,Outpatient,,,107.00,107.00,,62.86,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.86,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.8,48.41,,6.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,96.3,90,,77.04,Percent of Total Billed Charges,90% of Total Billed Charges,96.3,90,,77.04,Percent of Total Billed Charges,90% of Total Billed Charges,50.29,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,96.3,90,,77.04,Percent of Total Billed Charges,90% of Total Billed Charges,62.86,58.75,,89.768,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,50.29,47,,6.016,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,50.29,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,50.29,47,,40.232,Percent of Total Billed Charges,47% of Total Billed Charges,50.29,47,,40.232,Percent of Total Billed Charges,47% of Total Billed Charges,50.29,96.3,
THERAPUTTY,6208444,CDM,270,RC,99070,HCPCS,Outpatient,,,17.00,17.00,,9.99,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,22.848,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,22.184,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,22.184,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,22.184,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
LUMBAR SUPPORT,6208445,CDM,420,RC,99070,HCPCS,Outpatient,,,106.00,106.00,,62.28,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.28,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.31,48.41,,9.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,95.4,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,95.4,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,49.82,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,95.4,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,62.28,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.82,47,,9.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,49.82,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,150,100,,,Case Rate,Pays based on per visit rate,49.82,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,49.82,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,49.82,150,
WOUND CLEANSER 8 OZ,6208450,CDM,270,RC,,,Outpatient,,,44.00,44.00,,25.85,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.85,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.3,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,20.68,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,25.85,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,20.68,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,20.68,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,20.68,39.6,
SAFE CLENS 6 OZ,6208456,CDM,270,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,17.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,17.296,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
MULTI FLO ADAPTER,6208457,CDM,270,RC,,,Outpatient,,,25.00,25.00,,14.69,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.69,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.1,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,14.69,58.75,,13.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.75,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,22.5,
SUBCALVIAN CATHTRAY,6208460,CDM,270,RC,,,Outpatient,,,257.50,257.50,,151.28,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,151.28,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,124.66,48.41,,0.856,Percent of Total Billed Charges,48.41% of Total Billed Charges,231.75,90,,185.4,Percent of Total Billed Charges,90% of Total Billed Charges,231.75,90,,185.4,Percent of Total Billed Charges,90% of Total Billed Charges,121.03,47,,0.824,Percent of Total Billed Charges,47% of Total Billed Charges,231.75,90,,185.4,Percent of Total Billed Charges,90% of Total Billed Charges,151.28,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,121.03,47,,0.824,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,121.03,47,,0.824,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,121.03,47,,96.824,Percent of Total Billed Charges,47% of Total Billed Charges,121.03,47,,96.824,Percent of Total Billed Charges,47% of Total Billed Charges,121.03,231.75,
OPSITE 4X5 1/2 IN,6208463,CDM,270,RC,,,Outpatient,,,13.30,13.30,,7.81,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.81,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.44,48.41,,19.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.97,90,,9.576,Percent of Total Billed Charges,90% of Total Billed Charges,11.97,90,,9.576,Percent of Total Billed Charges,90% of Total Billed Charges,6.25,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,11.97,90,,9.576,Percent of Total Billed Charges,90% of Total Billed Charges,7.81,58.75,,10.808,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.25,47,,19.176,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.25,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.25,47,,5,Percent of Total Billed Charges,47% of Total Billed Charges,6.25,47,,5,Percent of Total Billed Charges,47% of Total Billed Charges,6.25,11.97,
DUODERM 4X4,6208464,CDM,270,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,23.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,22.936,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
DUODERM 4X5,6208465,CDM,270,RC,,,Outpatient,,,49.00,49.00,,28.79,58.75,,244.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.79,58.75,,244.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.72,48.41,,11.232,Percent of Total Billed Charges,48.41% of Total Billed Charges,44.1,90,,35.28,Percent of Total Billed Charges,90% of Total Billed Charges,44.1,90,,35.28,Percent of Total Billed Charges,90% of Total Billed Charges,23.03,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,44.1,90,,35.28,Percent of Total Billed Charges,90% of Total Billed Charges,28.79,58.75,,244.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.03,47,,10.904,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.03,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.03,47,,18.424,Percent of Total Billed Charges,47% of Total Billed Charges,23.03,47,,18.424,Percent of Total Billed Charges,47% of Total Billed Charges,23.03,44.1,
DUODERM 6X7,6208466,CDM,270,RC,,,Outpatient,,,47.00,47.00,,27.61,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.61,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.75,48.41,,25.944,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,22.09,47,,25.192,Percent of Total Billed Charges,47% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,27.61,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,25.192,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,22.09,47,,25.192,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,42.3,
CATH FOL 14FR 30CCTE,6208468,CDM,270,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
GASTROSTOMY TUBE,6208471,CDM,270,RC,,,Outpatient,,,51.00,51.00,,29.96,58.75,,29.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.96,58.75,,29.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.69,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,45.9,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,45.9,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,23.97,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,45.9,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,29.96,58.75,,29.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.97,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,45.9,
GASTROSTOMY KIT,6208472,CDM,270,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
STERI STRIP1/4X1 1/2,6208473,CDM,270,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,6.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,6.392,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
GLOVES STERILE SINGL,6208477,CDM,270,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,8.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,7.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
CLEAR STOMACH TUBE,6208478,CDM,270,RC,,,Outpatient,,,45.00,45.00,,26.44,58.75,,27.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,26.44,58.75,,27.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.78,48.41,,13.944,Percent of Total Billed Charges,48.41% of Total Billed Charges,40.5,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,40.5,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,26.44,58.75,,27.496,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.15,47,,13.536,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,21.15,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.15,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,21.15,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,21.15,40.5,
SPLINT THUMB-O,6208479,CDM,270,RC,,,Outpatient,,,44.00,44.00,,25.85,58.75,,3.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.85,58.75,,3.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.3,48.41,,10.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,20.68,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,25.85,58.75,,3.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,10.152,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,20.68,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,20.68,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,20.68,39.6,
DUODERM 2.5 X 2.5,6208481,CDM,270,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,5.032,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,4.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
ORTHO GLASS 1,6208482,CDM,270,RC,,,Outpatient,,,11.00,11.00,,6.46,58.75,,2.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.46,58.75,,2.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.33,48.41,,14.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,47,,14.064,Percent of Total Billed Charges,47% of Total Billed Charges,9.9,90,,7.92,Percent of Total Billed Charges,90% of Total Billed Charges,6.46,58.75,,2.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,14.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.17,47,,14.064,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,47,,4.136,Percent of Total Billed Charges,47% of Total Billed Charges,5.17,9.9,
ORTHO GLASS 3,6208483,CDM,270,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,9.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,37.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,9.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
ORTHO GLASS 4,6208484,CDM,270,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,93.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,93.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,15.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,93.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,15.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
ORTHO GLASS 6,6208485,CDM,270,RC,,,Outpatient,,,37.00,37.00,,21.74,58.75,,222.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.74,58.75,,222.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.91,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,33.3,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,33.3,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,17.39,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,33.3,90,,26.64,Percent of Total Billed Charges,90% of Total Billed Charges,21.74,58.75,,222.784,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.39,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.39,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.39,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,17.39,47,,13.912,Percent of Total Billed Charges,47% of Total Billed Charges,17.39,33.3,
NECK BRACE,6208487,CDM,570,RC,,,Outpatient,,,106.00,106.00,,62.28,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.28,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.31,48.41,,3.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,95.4,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,95.4,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,49.82,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,95.4,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,62.28,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.82,47,,3.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,49.82,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,49.82,95.4,
6 FR SUCTION CATH,6208491,CDM,270,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,20.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,20.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,20.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
5 1/4 SUCTION CATH,6208492,CDM,270,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,29.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,29.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,29.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
CATHETER STRAP,6208495,CDM,270,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
FOLEY LAT CATH STYLE,6208497,CDM,270,RC,,,Outpatient,,,164.00,164.00,,96.35,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.35,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,79.39,48.41,,24.008,Percent of Total Billed Charges,48.41% of Total Billed Charges,147.6,90,,118.08,Percent of Total Billed Charges,90% of Total Billed Charges,147.6,90,,118.08,Percent of Total Billed Charges,90% of Total Billed Charges,77.08,47,,23.312,Percent of Total Billed Charges,47% of Total Billed Charges,147.6,90,,118.08,Percent of Total Billed Charges,90% of Total Billed Charges,96.35,58.75,,22.088,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.08,47,,23.312,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,77.08,47,,23.312,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.08,47,,61.664,Percent of Total Billed Charges,47% of Total Billed Charges,77.08,47,,61.664,Percent of Total Billed Charges,47% of Total Billed Charges,77.08,147.6,
COBAN DRESSING,6208500,CDM,270,RC,,,Outpatient,,,8.80,8.80,,5.17,58.75,,60.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.17,58.75,,60.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.26,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.92,90,,6.336,Percent of Total Billed Charges,90% of Total Billed Charges,7.92,90,,6.336,Percent of Total Billed Charges,90% of Total Billed Charges,4.14,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,7.92,90,,6.336,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,58.75,,60.16,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.14,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.14,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.14,47,,3.312,Percent of Total Billed Charges,47% of Total Billed Charges,4.14,47,,3.312,Percent of Total Billed Charges,47% of Total Billed Charges,4.14,7.92,
OPSITE 2X3,6208504,CDM,270,RC,,,Outpatient,,,3.00,3.00,,1.76,58.75,,1.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.76,58.75,,1.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.45,48.41,,27.112,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,1.41,47,,26.32,Percent of Total Billed Charges,47% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,1.76,58.75,,1.88,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,26.32,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.41,47,,26.32,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,2.7,
MALE ADA PLU SHORT,6208505,CDM,270,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
L/BLT CAN,6208506,CDM,270,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,38.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,15.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,37.6,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
MORGAN LENS,6208508,CDM,270,RC,,,Outpatient,,,64.90,64.90,,38.13,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.13,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,31.42,48.41,,9.296,Percent of Total Billed Charges,48.41% of Total Billed Charges,58.41,90,,46.728,Percent of Total Billed Charges,90% of Total Billed Charges,58.41,90,,46.728,Percent of Total Billed Charges,90% of Total Billed Charges,30.5,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,58.41,90,,46.728,Percent of Total Billed Charges,90% of Total Billed Charges,38.13,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.5,47,,9.024,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,30.5,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,30.5,47,,24.4,Percent of Total Billed Charges,47% of Total Billed Charges,30.5,47,,24.4,Percent of Total Billed Charges,47% of Total Billed Charges,30.5,58.41,
EYE SHIELD ALUMINIUM,6208509,CDM,270,RC,,,Outpatient,,,33.00,33.00,,19.39,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.39,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.98,48.41,,38.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,29.7,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,29.7,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,15.51,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,29.7,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,19.39,58.75,,15.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,37.6,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.51,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,29.7,
DERMABOND,6208511,CDM,270,RC,,,Outpatient,,,92.00,92.00,,54.05,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,54.05,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.54,48.41,,17.04,Percent of Total Billed Charges,48.41% of Total Billed Charges,82.8,90,,66.24,Percent of Total Billed Charges,90% of Total Billed Charges,82.8,90,,66.24,Percent of Total Billed Charges,90% of Total Billed Charges,43.24,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,82.8,90,,66.24,Percent of Total Billed Charges,90% of Total Billed Charges,54.05,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,43.24,47,,16.544,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,43.24,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,43.24,47,,34.592,Percent of Total Billed Charges,47% of Total Billed Charges,43.24,47,,34.592,Percent of Total Billed Charges,47% of Total Billed Charges,43.24,82.8,
XEROFORM GAUZE,6208512,CDM,270,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,48.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,47,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
STERILE DRESSING 2X2,6208515,CDM,270,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,24.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,24.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,17.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,24.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,17.296,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
SUCTION IRRIG DISP,6208521,CDM,270,RC,,,Outpatient,,,254.00,254.00,,149.23,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,149.23,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,122.96,48.41,,46.864,Percent of Total Billed Charges,48.41% of Total Billed Charges,228.6,90,,182.88,Percent of Total Billed Charges,90% of Total Billed Charges,228.6,90,,182.88,Percent of Total Billed Charges,90% of Total Billed Charges,119.38,47,,45.496,Percent of Total Billed Charges,47% of Total Billed Charges,228.6,90,,182.88,Percent of Total Billed Charges,90% of Total Billed Charges,149.23,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,119.38,47,,45.496,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,119.38,47,,45.496,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,119.38,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,119.38,47,,95.504,Percent of Total Billed Charges,47% of Total Billed Charges,119.38,228.6,
POLY HESIVE II,6208524,CDM,270,RC,,,Outpatient,,,18.70,18.70,,10.99,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.99,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.05,48.41,,15.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.83,90,,13.464,Percent of Total Billed Charges,90% of Total Billed Charges,16.83,90,,13.464,Percent of Total Billed Charges,90% of Total Billed Charges,8.79,47,,14.888,Percent of Total Billed Charges,47% of Total Billed Charges,16.83,90,,13.464,Percent of Total Billed Charges,90% of Total Billed Charges,10.99,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.79,47,,14.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.79,47,,14.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.79,47,,7.032,Percent of Total Billed Charges,47% of Total Billed Charges,8.79,47,,7.032,Percent of Total Billed Charges,47% of Total Billed Charges,8.79,16.83,
BITE GAURD,6208526,CDM,270,RC,,,Outpatient,,,31.90,31.90,,18.74,58.75,,65.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.74,58.75,,65.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.44,48.41,,22.152,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.71,90,,22.968,Percent of Total Billed Charges,90% of Total Billed Charges,28.71,90,,22.968,Percent of Total Billed Charges,90% of Total Billed Charges,14.99,47,,21.504,Percent of Total Billed Charges,47% of Total Billed Charges,28.71,90,,22.968,Percent of Total Billed Charges,90% of Total Billed Charges,18.74,58.75,,65.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.99,47,,21.504,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.99,47,,21.504,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.99,47,,11.992,Percent of Total Billed Charges,47% of Total Billed Charges,14.99,47,,11.992,Percent of Total Billed Charges,47% of Total Billed Charges,14.99,28.71,
UNIVERSAL PACK,6208529,CDM,270,RC,,,Outpatient,,,191.00,191.00,,112.21,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,112.21,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,92.46,48.41,,29.824,Percent of Total Billed Charges,48.41% of Total Billed Charges,171.9,90,,137.52,Percent of Total Billed Charges,90% of Total Billed Charges,171.9,90,,137.52,Percent of Total Billed Charges,90% of Total Billed Charges,89.77,47,,28.952,Percent of Total Billed Charges,47% of Total Billed Charges,171.9,90,,137.52,Percent of Total Billed Charges,90% of Total Billed Charges,112.21,58.75,,33.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,89.77,47,,28.952,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,89.77,47,,28.952,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,89.77,47,,71.816,Percent of Total Billed Charges,47% of Total Billed Charges,89.77,47,,71.816,Percent of Total Billed Charges,47% of Total Billed Charges,89.77,171.9,
EZ WET KIT,6208530,CDM,270,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,10.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,9.776,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
STAPLER SINGLE USE,6208535,CDM,270,RC,,,Outpatient,,,28.00,28.00,,16.45,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,14.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,47,,14.064,Percent of Total Billed Charges,47% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,14.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,14.064,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,25.2,
POLYSORB 5-0,6208536,CDM,270,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,27.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,27.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,26.416,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,25.64,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,27.728,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,25.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,25.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
POLYSORB 4-0 27,6208539,CDM,270,RC,,,Outpatient,,,24.00,24.00,,14.1,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.1,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.62,48.41,,24.28,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.6,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,21.6,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,11.28,47,,23.576,Percent of Total Billed Charges,47% of Total Billed Charges,21.6,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,23.576,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.28,47,,23.576,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,21.6,
POLYSORB 3-0 27,6208540,CDM,270,RC,,,Outpatient,,,28.00,28.00,,16.45,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.45,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.55,48.41,,1.16,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,13.16,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,25.2,90,,20.16,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,1.128,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.16,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.16,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,47,,10.528,Percent of Total Billed Charges,47% of Total Billed Charges,13.16,25.2,
MONOSOF 4-0,6208552,CDM,270,RC,,,Outpatient,,,23.00,23.00,,13.51,58.75,,21.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.51,58.75,,21.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.13,48.41,,24.008,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,10.81,47,,23.312,Percent of Total Billed Charges,47% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,13.51,58.75,,21.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,23.312,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.81,47,,23.312,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,20.7,
MONOSOF 5-0,6208553,CDM,270,RC,,,Outpatient,,,23.00,23.00,,13.51,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.51,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.13,48.41,,53.832,Percent of Total Billed Charges,48.41% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,10.81,47,,52.264,Percent of Total Billed Charges,47% of Total Billed Charges,20.7,90,,16.56,Percent of Total Billed Charges,90% of Total Billed Charges,13.51,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,52.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.81,47,,52.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.81,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,47,,8.648,Percent of Total Billed Charges,47% of Total Billed Charges,10.81,20.7,
POLYSORB 3-0,6208558,CDM,270,RC,,,Outpatient,,,36.00,36.00,,21.15,58.75,,1.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.15,58.75,,1.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.43,48.41,,42.992,Percent of Total Billed Charges,48.41% of Total Billed Charges,32.4,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,32.4,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,16.92,47,,41.736,Percent of Total Billed Charges,47% of Total Billed Charges,32.4,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,58.75,,1.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.92,47,,41.736,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.92,47,,41.736,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.92,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,16.92,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,16.92,32.4,
TROCAR,6208568,CDM,270,RC,,,Outpatient,,,521.00,521.00,,306.09,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,306.09,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,252.22,48.41,,6.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,468.9,90,,375.12,Percent of Total Billed Charges,90% of Total Billed Charges,468.9,90,,375.12,Percent of Total Billed Charges,90% of Total Billed Charges,244.87,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,468.9,90,,375.12,Percent of Total Billed Charges,90% of Total Billed Charges,306.09,58.75,,23.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,244.87,47,,6.016,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,244.87,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,244.87,47,,195.896,Percent of Total Billed Charges,47% of Total Billed Charges,244.87,47,,195.896,Percent of Total Billed Charges,47% of Total Billed Charges,244.87,468.9,
EXTENSION SET,6208571,CDM,270,RC,,,Outpatient,,,10.00,10.00,,5.88,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.88,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.84,48.41,,3.408,Percent of Total Billed Charges,48.41% of Total Billed Charges,9,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,9,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,47,,3.312,Percent of Total Billed Charges,47% of Total Billed Charges,9,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,5.88,58.75,,28.672,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,3.312,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.7,47,,3.312,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,9,
SKIN STAPLE DISP 5SH,6208572,CDM,270,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,13.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
INFU-SURG INFUSER,6208573,CDM,270,RC,,,Outpatient,,,63.00,63.00,,37.01,58.75,,31.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.01,58.75,,31.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.5,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,56.7,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,56.7,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,29.61,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,56.7,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,37.01,58.75,,31.488,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.61,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,29.61,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.61,47,,23.688,Percent of Total Billed Charges,47% of Total Billed Charges,29.61,47,,23.688,Percent of Total Billed Charges,47% of Total Billed Charges,29.61,56.7,
HYDROGEL GAUZE,6208576,CDM,270,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,4.472,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,4.344,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,4.344,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,4.344,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
HYDROGEL,6208577,CDM,270,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,5.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,5.456,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
EZ STABILIZER EZ-10,6208578,CDM,270,RC,,,Outpatient,,,18.00,18.00,,10.58,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.58,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.71,48.41,,17.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,8.46,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,16.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,10.58,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,16.92,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.46,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,16.2,
Nail Remove Tray,6208579,CDM,270,RC,,,Outpatient,,,58.50,58.50,,34.37,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.37,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.32,48.41,,21.304,Percent of Total Billed Charges,48.41% of Total Billed Charges,52.65,90,,42.12,Percent of Total Billed Charges,90% of Total Billed Charges,52.65,90,,42.12,Percent of Total Billed Charges,90% of Total Billed Charges,27.5,47,,20.68,Percent of Total Billed Charges,47% of Total Billed Charges,52.65,90,,42.12,Percent of Total Billed Charges,90% of Total Billed Charges,34.37,58.75,,7.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.5,47,,20.68,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,27.5,47,,20.68,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.5,47,,22,Percent of Total Billed Charges,47% of Total Billed Charges,27.5,47,,22,Percent of Total Billed Charges,47% of Total Billed Charges,27.5,52.65,
Ostomy Skin Barrier,6208580,CDM,270,RC,,,Outpatient,,,7.80,7.80,,4.58,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.58,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.78,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.02,90,,5.616,Percent of Total Billed Charges,90% of Total Billed Charges,7.02,90,,5.616,Percent of Total Billed Charges,90% of Total Billed Charges,3.67,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,7.02,90,,5.616,Percent of Total Billed Charges,90% of Total Billed Charges,4.58,58.75,,9.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.67,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.67,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.67,47,,2.936,Percent of Total Billed Charges,47% of Total Billed Charges,3.67,47,,2.936,Percent of Total Billed Charges,47% of Total Billed Charges,3.67,7.02,
SPONGES SUPER 6X6,6208581,CDM,270,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,13.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,16.92,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,13.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
I & D Tray,6208582,CDM,270,RC,,,Outpatient,,,5.45,5.45,,3.2,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.2,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.64,48.41,,9.68,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.91,90,,3.928,Percent of Total Billed Charges,90% of Total Billed Charges,4.91,90,,3.928,Percent of Total Billed Charges,90% of Total Billed Charges,2.56,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,4.91,90,,3.928,Percent of Total Billed Charges,90% of Total Billed Charges,3.2,58.75,,12.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.56,47,,9.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.56,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.56,47,,2.048,Percent of Total Billed Charges,47% of Total Billed Charges,2.56,47,,2.048,Percent of Total Billed Charges,47% of Total Billed Charges,2.56,4.91,
GASTRO EAS FEEDTUBE,6208583,CDM,270,RC,,,Outpatient,,,79.00,79.00,,46.41,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,46.41,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,38.24,48.41,,2.848,Percent of Total Billed Charges,48.41% of Total Billed Charges,71.1,90,,56.88,Percent of Total Billed Charges,90% of Total Billed Charges,71.1,90,,56.88,Percent of Total Billed Charges,90% of Total Billed Charges,37.13,47,,2.76,Percent of Total Billed Charges,47% of Total Billed Charges,71.1,90,,56.88,Percent of Total Billed Charges,90% of Total Billed Charges,46.41,58.75,,6.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.13,47,,2.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,37.13,47,,2.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,37.13,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,37.13,47,,29.704,Percent of Total Billed Charges,47% of Total Billed Charges,37.13,71.1,
TROCAR CATHETERKIT,6208586,CDM,270,RC,,,Outpatient,,,198.00,198.00,,116.33,58.75,,17.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,116.33,58.75,,17.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,95.85,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,178.2,90,,142.56,Percent of Total Billed Charges,90% of Total Billed Charges,178.2,90,,142.56,Percent of Total Billed Charges,90% of Total Billed Charges,93.06,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,178.2,90,,142.56,Percent of Total Billed Charges,90% of Total Billed Charges,116.33,58.75,,17.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,93.06,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,93.06,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,93.06,47,,74.448,Percent of Total Billed Charges,47% of Total Billed Charges,93.06,47,,74.448,Percent of Total Billed Charges,47% of Total Billed Charges,93.06,178.2,
CHEST DRAIN SYSTEM,6208592,CDM,270,RC,,,Outpatient,,,474.00,474.00,,278.48,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,278.48,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,229.46,48.41,,5.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,426.6,90,,341.28,Percent of Total Billed Charges,90% of Total Billed Charges,426.6,90,,341.28,Percent of Total Billed Charges,90% of Total Billed Charges,222.78,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,426.6,90,,341.28,Percent of Total Billed Charges,90% of Total Billed Charges,278.48,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,222.78,47,,5.264,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,222.78,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,222.78,47,,178.224,Percent of Total Billed Charges,47% of Total Billed Charges,222.78,47,,178.224,Percent of Total Billed Charges,47% of Total Billed Charges,222.78,426.6,
BULKY 4X8,6208601,CDM,270,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,18.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
STAND COVER MAYO,6208607,CDM,270,RC,,,Outpatient,,,43.50,43.50,,25.56,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.56,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.06,48.41,,3.528,Percent of Total Billed Charges,48.41% of Total Billed Charges,39.15,90,,31.32,Percent of Total Billed Charges,90% of Total Billed Charges,39.15,90,,31.32,Percent of Total Billed Charges,90% of Total Billed Charges,20.45,47,,3.424,Percent of Total Billed Charges,47% of Total Billed Charges,39.15,90,,31.32,Percent of Total Billed Charges,90% of Total Billed Charges,25.56,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.45,47,,3.424,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,20.45,47,,3.424,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.45,47,,16.36,Percent of Total Billed Charges,47% of Total Billed Charges,20.45,47,,16.36,Percent of Total Billed Charges,47% of Total Billed Charges,20.45,39.15,
MEDFIX TAPE,6208614,CDM,270,RC,,,Outpatient,,,63.00,63.00,,37.01,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.01,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.5,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,56.7,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,56.7,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,29.61,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,56.7,90,,45.36,Percent of Total Billed Charges,90% of Total Billed Charges,37.01,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.61,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,29.61,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.61,47,,23.688,Percent of Total Billed Charges,47% of Total Billed Charges,29.61,47,,23.688,Percent of Total Billed Charges,47% of Total Billed Charges,29.61,56.7,
PLASTER SPLINT EACH,6208618,CDM,270,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,38.24,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,37.128,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,37.128,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,37.128,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
CASTING SCOTCH,6208625,CDM,270,RC,,,Outpatient,,,47.00,47.00,,27.61,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.61,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.75,48.41,,29.256,Percent of Total Billed Charges,48.41% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,22.09,47,,28.408,Percent of Total Billed Charges,47% of Total Billed Charges,42.3,90,,33.84,Percent of Total Billed Charges,90% of Total Billed Charges,27.61,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,28.408,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,22.09,47,,28.408,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,47,,17.672,Percent of Total Billed Charges,47% of Total Billed Charges,22.09,42.3,
METAL KNEE TIB/FIB,6208629,CDM,270,RC,,,Outpatient,,,128.00,128.00,,75.2,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.2,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.96,48.41,,2.208,Percent of Total Billed Charges,48.41% of Total Billed Charges,115.2,90,,92.16,Percent of Total Billed Charges,90% of Total Billed Charges,115.2,90,,92.16,Percent of Total Billed Charges,90% of Total Billed Charges,60.16,47,,2.144,Percent of Total Billed Charges,47% of Total Billed Charges,115.2,90,,92.16,Percent of Total Billed Charges,90% of Total Billed Charges,75.2,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,60.16,47,,2.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,60.16,47,,2.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,60.16,47,,48.128,Percent of Total Billed Charges,47% of Total Billed Charges,60.16,47,,48.128,Percent of Total Billed Charges,47% of Total Billed Charges,60.16,115.2,
WEBRIL,6208630,CDM,270,RC,,,Outpatient,,,4.00,4.00,,2.35,58.75,,29.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.35,58.75,,29.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.94,48.41,,8.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,3.6,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,3.6,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,1.88,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,3.6,90,,2.88,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,58.75,,29.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.88,47,,8.272,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.88,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.88,47,,1.504,Percent of Total Billed Charges,47% of Total Billed Charges,1.88,47,,1.504,Percent of Total Billed Charges,47% of Total Billed Charges,1.88,3.6,
CAST PLASTER 3,6208631,CDM,270,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,3.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,3.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
SCOTCHCAST PLUSS 2,6208632,CDM,270,RC,,,Outpatient,,,32.00,32.00,,18.8,58.75,,32.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.8,58.75,,32.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.49,48.41,,2.128,Percent of Total Billed Charges,48.41% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,15.04,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,28.8,90,,23.04,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,58.75,,32.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,2.072,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.04,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.04,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,47,,12.032,Percent of Total Billed Charges,47% of Total Billed Charges,15.04,28.8,
CAST FIBERGLASS2,6208633,CDM,270,RC,,,Outpatient,,,27.00,27.00,,15.86,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.86,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.07,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,24.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,24.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,12.69,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,24.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,15.86,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.69,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,24.3,
CAST FIBERGLASS3,6208634,CDM,270,RC,,,Outpatient,,,33.00,33.00,,19.39,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.39,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.98,48.41,,3.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,29.7,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,29.7,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,15.51,47,,3.456,Percent of Total Billed Charges,47% of Total Billed Charges,29.7,90,,23.76,Percent of Total Billed Charges,90% of Total Billed Charges,19.39,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,3.456,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.51,47,,3.456,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.51,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,47,,12.408,Percent of Total Billed Charges,47% of Total Billed Charges,15.51,29.7,
SCOTCHCAST PLUS3,6208635,CDM,270,RC,,,Outpatient,,,40.00,40.00,,23.5,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.5,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.36,48.41,,4.608,Percent of Total Billed Charges,48.41% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,47,,4.472,Percent of Total Billed Charges,47% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,23.5,58.75,,11.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,4.472,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.8,47,,4.472,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,36,
CAST PLASTER 2,6208636,CDM,270,RC,,,Outpatient,,,18.00,18.00,,10.58,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.58,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.71,48.41,,3.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,8.46,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,16.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,10.58,58.75,,47,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,3.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.46,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,16.2,
SCOTCH CAST PLUS 4,6208637,CDM,270,RC,,,Outpatient,,,52.00,52.00,,30.55,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.55,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.17,48.41,,5.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,46.8,90,,37.44,Percent of Total Billed Charges,90% of Total Billed Charges,46.8,90,,37.44,Percent of Total Billed Charges,90% of Total Billed Charges,24.44,47,,5.608,Percent of Total Billed Charges,47% of Total Billed Charges,46.8,90,,37.44,Percent of Total Billed Charges,90% of Total Billed Charges,30.55,58.75,,20.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.44,47,,5.608,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,24.44,47,,5.608,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.44,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,24.44,47,,19.552,Percent of Total Billed Charges,47% of Total Billed Charges,24.44,46.8,
STOCKINETTE FOOT,6208638,CDM,270,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,58.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,58.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,58.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
BUTTERFLY,6208644,CDM,270,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,21.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,21.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,71.992,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,69.896,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,21.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,69.896,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,69.896,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
BOOT WALKER,6208645,CDM,270,RC,,,Outpatient,,,139.00,139.00,,81.66,58.75,,56.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,81.66,58.75,,56.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,67.29,48.41,,2.504,Percent of Total Billed Charges,48.41% of Total Billed Charges,125.1,90,,100.08,Percent of Total Billed Charges,90% of Total Billed Charges,125.1,90,,100.08,Percent of Total Billed Charges,90% of Total Billed Charges,65.33,47,,2.432,Percent of Total Billed Charges,47% of Total Billed Charges,125.1,90,,100.08,Percent of Total Billed Charges,90% of Total Billed Charges,81.66,58.75,,56.872,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,65.33,47,,2.432,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,65.33,47,,2.432,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,65.33,47,,52.264,Percent of Total Billed Charges,47% of Total Billed Charges,65.33,47,,52.264,Percent of Total Billed Charges,47% of Total Billed Charges,65.33,125.1,
URINARY LEG BAGSYS,6208646,CDM,270,RC,,,Outpatient,,,71.00,71.00,,41.71,58.75,,18.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.71,58.75,,18.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.37,48.41,,1.528,Percent of Total Billed Charges,48.41% of Total Billed Charges,63.9,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,63.9,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,33.37,47,,1.488,Percent of Total Billed Charges,47% of Total Billed Charges,63.9,90,,51.12,Percent of Total Billed Charges,90% of Total Billed Charges,41.71,58.75,,18.616,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.37,47,,1.488,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,33.37,47,,1.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,33.37,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,33.37,47,,26.696,Percent of Total Billed Charges,47% of Total Billed Charges,33.37,63.9,
UNNA BOOT,6208647,CDM,270,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,26.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,26.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,3.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,26.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,3.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
ARM SLING POUCH,6208649,CDM,270,RC,,,Outpatient,,,16.00,16.00,,9.4,58.75,,36.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.4,58.75,,36.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.75,48.41,,2.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.4,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,14.4,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,7.52,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,14.4,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,58.75,,36.192,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.52,47,,2.632,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.52,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.52,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,7.52,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,7.52,14.4,
ANKLE STABILIZER H&L,6208651,CDM,270,RC,,,Outpatient,,,59.00,59.00,,34.66,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.66,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.56,48.41,,47.168,Percent of Total Billed Charges,48.41% of Total Billed Charges,53.1,90,,42.48,Percent of Total Billed Charges,90% of Total Billed Charges,53.1,90,,42.48,Percent of Total Billed Charges,90% of Total Billed Charges,27.73,47,,45.8,Percent of Total Billed Charges,47% of Total Billed Charges,53.1,90,,42.48,Percent of Total Billed Charges,90% of Total Billed Charges,34.66,58.75,,12.224,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.73,47,,45.8,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,27.73,47,,45.8,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.73,47,,22.184,Percent of Total Billed Charges,47% of Total Billed Charges,27.73,47,,22.184,Percent of Total Billed Charges,47% of Total Billed Charges,27.73,53.1,
ARM SLING/ SWATHE,6208653,CDM,270,RC,,,Outpatient,,,25.00,25.00,,14.69,58.75,,17.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.69,58.75,,17.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.1,48.41,,7.36,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,14.69,58.75,,17.576,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,7.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.75,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,22.5,
DRSNG 4 BULKY KLING,6208654,CDM,270,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,32.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,32.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.16,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,32.056,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.128,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
DEFIB ELECTRODES AD,6208655,CDM,270,RC,,,Outpatient,,,46.00,46.00,,27.03,58.75,,29.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.03,58.75,,29.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.27,48.41,,3.096,Percent of Total Billed Charges,48.41% of Total Billed Charges,41.4,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,41.4,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,21.62,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,41.4,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,27.03,58.75,,29.472,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.62,47,,3.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,21.62,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.62,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,21.62,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,21.62,41.4,
KERLIX SUPER SPONGES,6208657,CDM,270,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
4X4 GAUZE SPONGE,6208658,CDM,270,RC,,,Outpatient,,,2.20,2.20,,1.29,58.75,,29.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.29,58.75,,29.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.07,48.41,,5.808,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.98,90,,1.584,Percent of Total Billed Charges,90% of Total Billed Charges,1.98,90,,1.584,Percent of Total Billed Charges,90% of Total Billed Charges,1.03,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,1.98,90,,1.584,Percent of Total Billed Charges,90% of Total Billed Charges,1.29,58.75,,29.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.03,47,,5.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.03,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.03,47,,0.824,Percent of Total Billed Charges,47% of Total Billed Charges,1.03,47,,0.824,Percent of Total Billed Charges,47% of Total Billed Charges,1.03,1.98,
CRUTCHES CHILD,6208659,CDM,270,RC,,,Outpatient,,,51.00,51.00,,29.96,58.75,,65.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.96,58.75,,65.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.69,48.41,,10.688,Percent of Total Billed Charges,48.41% of Total Billed Charges,45.9,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,45.9,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,23.97,47,,10.376,Percent of Total Billed Charges,47% of Total Billed Charges,45.9,90,,36.72,Percent of Total Billed Charges,90% of Total Billed Charges,29.96,58.75,,65.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,10.376,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.97,47,,10.376,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.97,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,47,,19.176,Percent of Total Billed Charges,47% of Total Billed Charges,23.97,45.9,
CRUTCHES YOUTH PR,6208660,CDM,270,RC,,,Outpatient,,,61.00,61.00,,35.84,58.75,,52.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.84,58.75,,52.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.53,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,54.9,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,54.9,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,28.67,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,54.9,90,,43.92,Percent of Total Billed Charges,90% of Total Billed Charges,35.84,58.75,,52.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.67,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.67,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,47,,22.936,Percent of Total Billed Charges,47% of Total Billed Charges,28.67,54.9,
CRUTCHES MED ADULT,6208661,CDM,270,RC,,,Outpatient,,,29.00,29.00,,17.04,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.04,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.04,48.41,,4.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,26.1,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,26.1,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,13.63,47,,4.416,Percent of Total Billed Charges,47% of Total Billed Charges,26.1,90,,20.88,Percent of Total Billed Charges,90% of Total Billed Charges,17.04,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.63,47,,4.416,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.63,47,,4.416,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.63,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,13.63,47,,10.904,Percent of Total Billed Charges,47% of Total Billed Charges,13.63,26.1,
EXUDERM SACRUM 6X6,6208663,CDM,270,RC,,,Outpatient,,,67.00,67.00,,39.36,58.75,,4.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,39.36,58.75,,4.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.43,48.41,,4.008,Percent of Total Billed Charges,48.41% of Total Billed Charges,60.3,90,,48.24,Percent of Total Billed Charges,90% of Total Billed Charges,60.3,90,,48.24,Percent of Total Billed Charges,90% of Total Billed Charges,31.49,47,,3.888,Percent of Total Billed Charges,47% of Total Billed Charges,60.3,90,,48.24,Percent of Total Billed Charges,90% of Total Billed Charges,39.36,58.75,,4.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.49,47,,3.888,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,31.49,47,,3.888,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,31.49,47,,25.192,Percent of Total Billed Charges,47% of Total Billed Charges,31.49,47,,25.192,Percent of Total Billed Charges,47% of Total Billed Charges,31.49,60.3,
OSTOMY DRAIN P 2 1/4,6208664,CDM,270,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,12.024,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,11.672,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,11.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,11.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
OSTOMY DRAIN P 2 3/4,6208665,CDM,270,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,7.552,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,7.336,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,7.336,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,7.336,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
DUODERM 6X6,6208666,CDM,270,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,5.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,5.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,5.888,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,5.712,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,5.432,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,5.712,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,5.712,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
IODOFORM 1/2,6208667,CDM,270,RC,,,Outpatient,,,17.00,17.00,,9.99,58.75,,6.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.99,58.75,,6.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,48.41,,5.384,Percent of Total Billed Charges,48.41% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,7.99,47,,5.224,Percent of Total Billed Charges,47% of Total Billed Charges,15.3,90,,12.24,Percent of Total Billed Charges,90% of Total Billed Charges,9.99,58.75,,6.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,5.224,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.99,47,,5.224,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,47,,6.392,Percent of Total Billed Charges,47% of Total Billed Charges,7.99,15.3,
IODOFORM 1,6208668,CDM,270,RC,,,Outpatient,,,20.90,20.90,,12.28,58.75,,21.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.28,58.75,,21.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.12,48.41,,8.304,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,9.82,47,,8.064,Percent of Total Billed Charges,47% of Total Billed Charges,18.81,90,,15.048,Percent of Total Billed Charges,90% of Total Billed Charges,12.28,58.75,,21.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,8.064,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.82,47,,8.064,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,47,,7.856,Percent of Total Billed Charges,47% of Total Billed Charges,9.82,18.81,
ARM SLING XLG,6208669,CDM,270,RC,,,Outpatient,,,36.00,36.00,,21.15,58.75,,25.848,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.15,58.75,,25.848,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.43,48.41,,13.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,32.4,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,32.4,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,16.92,47,,13.256,Percent of Total Billed Charges,47% of Total Billed Charges,32.4,90,,25.92,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,58.75,,25.848,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.92,47,,13.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.92,47,,13.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.92,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,16.92,47,,13.536,Percent of Total Billed Charges,47% of Total Billed Charges,16.92,32.4,
STOMAHESIVE WAF23/4,6208670,CDM,270,RC,,,Outpatient,,,27.00,27.00,,15.86,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.86,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.07,48.41,,8.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,24.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,24.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,12.69,47,,8.088,Percent of Total Billed Charges,47% of Total Billed Charges,24.3,90,,19.44,Percent of Total Billed Charges,90% of Total Billed Charges,15.86,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,8.088,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.69,47,,8.088,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.69,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,47,,10.152,Percent of Total Billed Charges,47% of Total Billed Charges,12.69,24.3,
IODOFORM 1/4,6208671,CDM,270,RC,,,Outpatient,,,13.00,13.00,,7.64,58.75,,16.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.64,58.75,,16.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.29,48.41,,42.832,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,6.11,47,,41.584,Percent of Total Billed Charges,47% of Total Billed Charges,11.7,90,,9.36,Percent of Total Billed Charges,90% of Total Billed Charges,7.64,58.75,,16.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,41.584,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.11,47,,41.584,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,47,,4.888,Percent of Total Billed Charges,47% of Total Billed Charges,6.11,11.7,
TED HOSE THIGH ALL,6208672,CDM,270,RC,,,Outpatient,,,37.40,37.40,,21.97,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.97,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.11,48.41,,5.112,Percent of Total Billed Charges,48.41% of Total Billed Charges,33.66,90,,26.928,Percent of Total Billed Charges,90% of Total Billed Charges,33.66,90,,26.928,Percent of Total Billed Charges,90% of Total Billed Charges,17.58,47,,4.96,Percent of Total Billed Charges,47% of Total Billed Charges,33.66,90,,26.928,Percent of Total Billed Charges,90% of Total Billed Charges,21.97,58.75,,11.752,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.58,47,,4.96,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.58,47,,4.96,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.58,47,,14.064,Percent of Total Billed Charges,47% of Total Billed Charges,17.58,47,,14.064,Percent of Total Billed Charges,47% of Total Billed Charges,17.58,33.66,
TED HOSE KNEE ALL,6208673,CDM,270,RC,,,Outpatient,,,25.00,25.00,,14.69,58.75,,3.456,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.69,58.75,,3.456,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.1,48.41,,33.696,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,14.69,58.75,,3.456,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,32.712,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.75,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,22.5,
FEEDING BAG,6208674,CDM,270,RC,,,Outpatient,,,40.00,40.00,,23.5,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.5,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.36,48.41,,6.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,18.8,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,36,90,,28.8,Percent of Total Billed Charges,90% of Total Billed Charges,23.5,58.75,,2.352,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,6.016,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.8,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.8,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,47,,15.04,Percent of Total Billed Charges,47% of Total Billed Charges,18.8,36,
GASTRIC SUMP TUBE,6208675,CDM,270,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,7.96,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,7.728,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,6.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.728,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,7.728,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
24 GA IV CATH,6208676,CDM,270,RC,,,Outpatient,,,10.00,10.00,,5.88,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.88,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.84,48.41,,3.432,Percent of Total Billed Charges,48.41% of Total Billed Charges,9,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,9,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,47,,3.328,Percent of Total Billed Charges,47% of Total Billed Charges,9,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,5.88,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,3.328,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.7,47,,3.328,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,9,
DISP LACERATIONTRAY,6208677,CDM,270,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,4.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,4.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,1.872,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,1.816,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,4.28,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,1.816,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,1.816,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
NU-BREDE 4X4,6208678,CDM,270,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,7.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,7.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
SPLINT 1 MATERIAL,6208679,CDM,270,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,46.416,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,46.416,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,41.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,46.416,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,39.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
SPLINT 2 FABRICATION,6208680,CDM,270,RC,,,Outpatient,,,62.00,62.00,,36.43,58.75,,35.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.43,58.75,,35.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.01,48.41,,77.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,55.8,90,,44.64,Percent of Total Billed Charges,90% of Total Billed Charges,55.8,90,,44.64,Percent of Total Billed Charges,90% of Total Billed Charges,29.14,47,,74.824,Percent of Total Billed Charges,47% of Total Billed Charges,55.8,90,,44.64,Percent of Total Billed Charges,90% of Total Billed Charges,36.43,58.75,,35.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.14,47,,74.824,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,29.14,47,,74.824,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.14,47,,23.312,Percent of Total Billed Charges,47% of Total Billed Charges,29.14,47,,23.312,Percent of Total Billed Charges,47% of Total Billed Charges,29.14,55.8,
SPLINT 2 MATERIAL,6208681,CDM,270,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,2.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,2.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,104.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,101.896,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,2.68,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,101.896,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,101.896,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
SPLINT 3 FABRICATION,6208682,CDM,270,RC,,,Outpatient,,,70.00,70.00,,41.13,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.13,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.89,48.41,,136.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,63,90,,50.4,Percent of Total Billed Charges,90% of Total Billed Charges,63,90,,50.4,Percent of Total Billed Charges,90% of Total Billed Charges,32.9,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,63,90,,50.4,Percent of Total Billed Charges,90% of Total Billed Charges,41.13,58.75,,10.344,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.9,47,,132.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,32.9,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.9,47,,26.32,Percent of Total Billed Charges,47% of Total Billed Charges,32.9,47,,26.32,Percent of Total Billed Charges,47% of Total Billed Charges,32.9,63,
SPLINT 3 MATERIAL,6208683,CDM,270,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,136.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,4.232,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,132.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
SPLINT 4 FABRICATION,6208684,CDM,270,RC,,,Outpatient,,,100.00,100.00,,58.75,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.75,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.41,48.41,,136.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,90,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,90,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,47,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,90,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,58.75,58.75,,2.584,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47,47,,132.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,47,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,47,90,
SPLINT 4 MATERIAL,6208685,CDM,270,RC,,,Outpatient,,,24.00,24.00,,14.1,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.1,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.62,48.41,,136.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,21.6,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,21.6,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,11.28,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,21.6,90,,17.28,Percent of Total Billed Charges,90% of Total Billed Charges,14.1,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,132.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.28,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.28,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,47,,9.024,Percent of Total Billed Charges,47% of Total Billed Charges,11.28,21.6,
SPLINT 5 FABRICATION,6208686,CDM,270,RC,,,Outpatient,,,100.00,100.00,,58.75,58.75,,4.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.75,58.75,,4.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.41,48.41,,136.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,90,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,90,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,47,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,90,90,,72,Percent of Total Billed Charges,90% of Total Billed Charges,58.75,58.75,,4.328,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47,47,,132.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,47,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,47,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,47,47,,37.6,Percent of Total Billed Charges,47% of Total Billed Charges,47,90,
SPLINT 5 MATERIAL,6208687,CDM,270,RC,,,Outpatient,,,44.00,44.00,,25.85,58.75,,5.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,25.85,58.75,,5.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.3,48.41,,136.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,20.68,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,39.6,90,,31.68,Percent of Total Billed Charges,90% of Total Billed Charges,25.85,58.75,,5.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,132.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,20.68,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,20.68,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,20.68,47,,16.544,Percent of Total Billed Charges,47% of Total Billed Charges,20.68,39.6,
SPLINT 6 FABRICATION,6208688,CDM,270,RC,,,Outpatient,,,125.00,125.00,,73.44,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,73.44,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,60.51,48.41,,136.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,112.5,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,112.5,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,58.75,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,112.5,90,,90,Percent of Total Billed Charges,90% of Total Billed Charges,73.44,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,58.75,47,,132.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,58.75,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,58.75,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,58.75,47,,47,Percent of Total Billed Charges,47% of Total Billed Charges,58.75,112.5,
SPLINT 6 MATERIAL,6208689,CDM,270,RC,,,Outpatient,,,46.00,46.00,,27.03,58.75,,7.016,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.03,58.75,,7.016,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.27,48.41,,136.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,41.4,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,41.4,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,21.62,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,41.4,90,,33.12,Percent of Total Billed Charges,90% of Total Billed Charges,27.03,58.75,,7.016,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.62,47,,132.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,21.62,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.62,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,21.62,47,,17.296,Percent of Total Billed Charges,47% of Total Billed Charges,21.62,41.4,
SPLINT 7 FABRICATION,6208690,CDM,270,RC,,,Outpatient,,,121.00,121.00,,71.09,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,71.09,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.58,48.41,,136.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,108.9,90,,87.12,Percent of Total Billed Charges,90% of Total Billed Charges,108.9,90,,87.12,Percent of Total Billed Charges,90% of Total Billed Charges,56.87,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,108.9,90,,87.12,Percent of Total Billed Charges,90% of Total Billed Charges,71.09,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,56.87,47,,132.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,56.87,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,56.87,47,,45.496,Percent of Total Billed Charges,47% of Total Billed Charges,56.87,47,,45.496,Percent of Total Billed Charges,47% of Total Billed Charges,56.87,108.9,
"BAIR HUGGER, DISP.",6208692,CDM,270,RC,,,Outpatient,,,39.60,39.60,,23.27,58.75,,87.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.27,58.75,,87.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.17,48.41,,136.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,35.64,90,,28.512,Percent of Total Billed Charges,90% of Total Billed Charges,35.64,90,,28.512,Percent of Total Billed Charges,90% of Total Billed Charges,18.61,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,35.64,90,,28.512,Percent of Total Billed Charges,90% of Total Billed Charges,23.27,58.75,,87.376,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.61,47,,132.352,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.61,47,,132.352,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.61,47,,14.888,Percent of Total Billed Charges,47% of Total Billed Charges,18.61,47,,14.888,Percent of Total Billed Charges,47% of Total Billed Charges,18.61,35.64,
DISP ELECT SNARE COL,6208693,CDM,270,RC,,,Outpatient,,,57.20,57.20,,33.61,58.75,,3.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.61,58.75,,3.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.69,48.41,,363.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,51.48,90,,41.184,Percent of Total Billed Charges,90% of Total Billed Charges,51.48,90,,41.184,Percent of Total Billed Charges,90% of Total Billed Charges,26.88,47,,352.504,Percent of Total Billed Charges,47% of Total Billed Charges,51.48,90,,41.184,Percent of Total Billed Charges,90% of Total Billed Charges,33.61,58.75,,3.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.88,47,,352.504,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,26.88,47,,352.504,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.88,47,,21.504,Percent of Total Billed Charges,47% of Total Billed Charges,26.88,47,,21.504,Percent of Total Billed Charges,47% of Total Billed Charges,26.88,51.48,
DISP ELECT SNARE EGD,6208694,CDM,270,RC,,,Outpatient,,,77.00,77.00,,45.24,58.75,,1.856,Percent of Total Billed Charges,58.75% of Total Billed Charges,45.24,58.75,,1.856,Percent of Total Billed Charges,58.75% of Total Billed Charges,37.28,48.41,,285.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,69.3,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,69.3,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,36.19,47,,277.304,Percent of Total Billed Charges,47% of Total Billed Charges,69.3,90,,55.44,Percent of Total Billed Charges,90% of Total Billed Charges,45.24,58.75,,1.856,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,36.19,47,,277.304,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,36.19,47,,277.304,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,36.19,47,,28.952,Percent of Total Billed Charges,47% of Total Billed Charges,36.19,47,,28.952,Percent of Total Billed Charges,47% of Total Billed Charges,36.19,69.3,
FOLEY 18 FR 3 WAY,6208695,CDM,270,RC,,,Outpatient,,,26.00,26.00,,15.28,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.28,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.59,48.41,,438.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,23.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,23.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,12.22,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,23.4,90,,18.72,Percent of Total Billed Charges,90% of Total Billed Charges,15.28,58.75,,4.704,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.22,47,,425.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.22,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.22,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,12.22,47,,9.776,Percent of Total Billed Charges,47% of Total Billed Charges,12.22,23.4,
SHOE POST OP MALE,6208696,CDM,270,RC,,,Outpatient,,,37.40,37.40,,21.97,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.97,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.11,48.41,,398.608,Percent of Total Billed Charges,48.41% of Total Billed Charges,33.66,90,,26.928,Percent of Total Billed Charges,90% of Total Billed Charges,33.66,90,,26.928,Percent of Total Billed Charges,90% of Total Billed Charges,17.58,47,,387,Percent of Total Billed Charges,47% of Total Billed Charges,33.66,90,,26.928,Percent of Total Billed Charges,90% of Total Billed Charges,21.97,58.75,,3.288,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.58,47,,387,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.58,47,,387,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.58,47,,14.064,Percent of Total Billed Charges,47% of Total Billed Charges,17.58,47,,14.064,Percent of Total Billed Charges,47% of Total Billed Charges,17.58,33.66,
"ANKLE BRACE, VINYL L",6208697,CDM,270,RC,,,Outpatient,,,68.20,68.20,,40.07,58.75,,57.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,40.07,58.75,,57.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,33.02,48.41,,1177.328,Percent of Total Billed Charges,48.41% of Total Billed Charges,61.38,90,,49.104,Percent of Total Billed Charges,90% of Total Billed Charges,61.38,90,,49.104,Percent of Total Billed Charges,90% of Total Billed Charges,32.05,47,,1143.04,Percent of Total Billed Charges,47% of Total Billed Charges,61.38,90,,49.104,Percent of Total Billed Charges,90% of Total Billed Charges,40.07,58.75,,57.248,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.05,47,,1143.04,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,32.05,47,,1143.04,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,32.05,47,,25.64,Percent of Total Billed Charges,47% of Total Billed Charges,32.05,47,,25.64,Percent of Total Billed Charges,47% of Total Billed Charges,32.05,61.38,
ANKLE BRACE VINL S/M,6208698,CDM,270,RC,,,Outpatient,,,62.70,62.70,,36.84,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.84,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.35,48.41,,259.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,56.43,90,,45.144,Percent of Total Billed Charges,90% of Total Billed Charges,56.43,90,,45.144,Percent of Total Billed Charges,90% of Total Billed Charges,29.47,47,,252.088,Percent of Total Billed Charges,47% of Total Billed Charges,56.43,90,,45.144,Percent of Total Billed Charges,90% of Total Billed Charges,36.84,58.75,,8.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.47,47,,252.088,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,29.47,47,,252.088,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.47,47,,23.576,Percent of Total Billed Charges,47% of Total Billed Charges,29.47,47,,23.576,Percent of Total Billed Charges,47% of Total Billed Charges,29.47,56.43,
TUBE GAUZE DRESSING,6208699,CDM,270,RC,,,Outpatient,,,3.00,3.00,,1.76,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.76,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.45,48.41,,259.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,1.41,47,,252.088,Percent of Total Billed Charges,47% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,1.76,58.75,,1.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,252.088,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.41,47,,252.088,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,2.7,
VAC PUMP-CANISTR/GEL,6208701,CDM,270,RC,,,Outpatient,,,62.00,62.00,,36.43,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.43,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,30.01,48.41,,1070.232,Percent of Total Billed Charges,48.41% of Total Billed Charges,55.8,90,,44.64,Percent of Total Billed Charges,90% of Total Billed Charges,55.8,90,,44.64,Percent of Total Billed Charges,90% of Total Billed Charges,29.14,47,,1039.056,Percent of Total Billed Charges,47% of Total Billed Charges,55.8,90,,44.64,Percent of Total Billed Charges,90% of Total Billed Charges,36.43,58.75,,3.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.14,47,,1039.056,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,29.14,47,,1039.056,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,29.14,47,,23.312,Percent of Total Billed Charges,47% of Total Billed Charges,29.14,47,,23.312,Percent of Total Billed Charges,47% of Total Billed Charges,29.14,55.8,
VAC THERAPY UNIT,6208702,CDM,270,RC,,,Outpatient,,,139.00,139.00,,81.66,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,81.66,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,67.29,48.41,,259.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,125.1,90,,100.08,Percent of Total Billed Charges,90% of Total Billed Charges,125.1,90,,100.08,Percent of Total Billed Charges,90% of Total Billed Charges,65.33,47,,252.088,Percent of Total Billed Charges,47% of Total Billed Charges,125.1,90,,100.08,Percent of Total Billed Charges,90% of Total Billed Charges,81.66,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,65.33,47,,252.088,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,65.33,47,,252.088,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,65.33,47,,52.264,Percent of Total Billed Charges,47% of Total Billed Charges,65.33,47,,52.264,Percent of Total Billed Charges,47% of Total Billed Charges,65.33,125.1,
ACTICOAT MOISTURE4X8,6208703,CDM,270,RC,,,Outpatient,,,111.00,111.00,,65.21,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,65.21,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,53.74,48.41,,259.648,Percent of Total Billed Charges,48.41% of Total Billed Charges,99.9,90,,79.92,Percent of Total Billed Charges,90% of Total Billed Charges,99.9,90,,79.92,Percent of Total Billed Charges,90% of Total Billed Charges,52.17,47,,252.088,Percent of Total Billed Charges,47% of Total Billed Charges,99.9,90,,79.92,Percent of Total Billed Charges,90% of Total Billed Charges,65.21,58.75,,7.048,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,52.17,47,,252.088,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,52.17,47,,252.088,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,52.17,47,,41.736,Percent of Total Billed Charges,47% of Total Billed Charges,52.17,47,,41.736,Percent of Total Billed Charges,47% of Total Billed Charges,52.17,99.9,
KNEE SUPPORT,6208704,CDM,270,RC,,,Outpatient,,,16.00,16.00,,9.4,58.75,,12.976,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.4,58.75,,12.976,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.75,48.41,,139.848,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.4,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,14.4,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,7.52,47,,135.776,Percent of Total Billed Charges,47% of Total Billed Charges,14.4,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,58.75,,12.976,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.52,47,,135.776,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.52,47,,135.776,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.52,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,7.52,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,7.52,14.4,
FOLEY CATH 8-10FR,6208707,CDM,270,RC,,,Outpatient,,,8.80,8.80,,5.17,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.17,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.26,48.41,,153.824,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.92,90,,6.336,Percent of Total Billed Charges,90% of Total Billed Charges,7.92,90,,6.336,Percent of Total Billed Charges,90% of Total Billed Charges,4.14,47,,149.344,Percent of Total Billed Charges,47% of Total Billed Charges,7.92,90,,6.336,Percent of Total Billed Charges,90% of Total Billed Charges,5.17,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.14,47,,149.344,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.14,47,,149.344,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.14,47,,3.312,Percent of Total Billed Charges,47% of Total Billed Charges,4.14,47,,3.312,Percent of Total Billed Charges,47% of Total Billed Charges,4.14,7.92,
FOLEY CATH 12 FR,6208708,CDM,270,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,5.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,5.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,176.984,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,171.832,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,5.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,171.832,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,171.832,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
"BANDAGE, CO-FLEX 1",6208709,CDM,270,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,4.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,4.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,233.824,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,227.008,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,4.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,227.008,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,227.008,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
IV CATH SYSTEM BD,6208710,CDM,270,RC,,,Outpatient,,,11.55,11.55,,6.79,58.75,,14.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.79,58.75,,14.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.59,48.41,,257.192,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.4,90,,8.32,Percent of Total Billed Charges,90% of Total Billed Charges,10.4,90,,8.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.43,47,,249.704,Percent of Total Billed Charges,47% of Total Billed Charges,10.4,90,,8.32,Percent of Total Billed Charges,90% of Total Billed Charges,6.79,58.75,,14.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.43,47,,249.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.43,47,,249.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.43,47,,4.344,Percent of Total Billed Charges,47% of Total Billed Charges,5.43,47,,4.344,Percent of Total Billed Charges,47% of Total Billed Charges,5.43,10.4,
ACTICOAT 4X4,6208712,CDM,270,RC,,,Outpatient,,,14.50,14.50,,8.52,58.75,,9.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.52,58.75,,9.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.02,48.41,,151.464,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.05,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,13.05,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,6.82,47,,147.056,Percent of Total Billed Charges,47% of Total Billed Charges,13.05,90,,10.44,Percent of Total Billed Charges,90% of Total Billed Charges,8.52,58.75,,9.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.82,47,,147.056,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.82,47,,147.056,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.82,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,6.82,47,,5.456,Percent of Total Billed Charges,47% of Total Billed Charges,6.82,13.05,
SPLINT LEG ALUM/ PAD,6208713,CDM,270,RC,,,Outpatient,,,45.00,45.00,,26.44,58.75,,7.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,26.44,58.75,,7.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.78,48.41,,169.24,Percent of Total Billed Charges,48.41% of Total Billed Charges,40.5,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,40.5,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,21.15,47,,164.312,Percent of Total Billed Charges,47% of Total Billed Charges,40.5,90,,32.4,Percent of Total Billed Charges,90% of Total Billed Charges,26.44,58.75,,7.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.15,47,,164.312,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,21.15,47,,164.312,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.15,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,21.15,47,,16.92,Percent of Total Billed Charges,47% of Total Billed Charges,21.15,40.5,
REV KNUCK BEND SPLIN,6208715,CDM,270,RC,,,Outpatient,,,55.00,55.00,,32.31,58.75,,6.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,32.31,58.75,,6.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,26.63,48.41,,194.8,Percent of Total Billed Charges,48.41% of Total Billed Charges,49.5,90,,39.6,Percent of Total Billed Charges,90% of Total Billed Charges,49.5,90,,39.6,Percent of Total Billed Charges,90% of Total Billed Charges,25.85,47,,189.128,Percent of Total Billed Charges,47% of Total Billed Charges,49.5,90,,39.6,Percent of Total Billed Charges,90% of Total Billed Charges,32.31,58.75,,6.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,25.85,47,,189.128,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,25.85,47,,189.128,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,25.85,47,,20.68,Percent of Total Billed Charges,47% of Total Billed Charges,25.85,47,,20.68,Percent of Total Billed Charges,47% of Total Billed Charges,25.85,49.5,
PATIENT SLIPPERS,6208716,CDM,270,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,10.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,10.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,257.192,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,249.704,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,10.08,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,249.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,249.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
RHINO PACKING,6208717,CDM,270,RC,,,Outpatient,,,35.00,35.00,,20.56,58.75,,16.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.56,58.75,,16.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.94,48.41,,283.104,Percent of Total Billed Charges,48.41% of Total Billed Charges,31.5,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,31.5,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,16.45,47,,274.856,Percent of Total Billed Charges,47% of Total Billed Charges,31.5,90,,25.2,Percent of Total Billed Charges,90% of Total Billed Charges,20.56,58.75,,16.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.45,47,,274.856,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.45,47,,274.856,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.45,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,16.45,47,,13.16,Percent of Total Billed Charges,47% of Total Billed Charges,16.45,31.5,
FOLEY 3 WAY,6208720,CDM,270,RC,,,Outpatient,,,25.00,25.00,,14.69,58.75,,10.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.69,58.75,,10.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.1,48.41,,863.576,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,47,,838.424,Percent of Total Billed Charges,47% of Total Billed Charges,22.5,90,,18,Percent of Total Billed Charges,90% of Total Billed Charges,14.69,58.75,,10.104,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,838.424,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.75,47,,838.424,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.75,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,47,,9.4,Percent of Total Billed Charges,47% of Total Billed Charges,11.75,22.5,
NACL 09 3000 ML,6208721,CDM,270,RC,,,Outpatient,,,7.35,7.35,,4.32,58.75,,51.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.32,58.75,,51.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.56,48.41,,4.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.62,90,,5.296,Percent of Total Billed Charges,90% of Total Billed Charges,6.62,90,,5.296,Percent of Total Billed Charges,90% of Total Billed Charges,3.45,47,,4.016,Percent of Total Billed Charges,47% of Total Billed Charges,6.62,90,,5.296,Percent of Total Billed Charges,90% of Total Billed Charges,4.32,58.75,,51.984,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.45,47,,4.016,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.45,47,,4.016,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.45,47,,2.76,Percent of Total Billed Charges,47% of Total Billed Charges,3.45,47,,2.76,Percent of Total Billed Charges,47% of Total Billed Charges,3.45,6.62,
TUP SET,6208722,CDM,270,RC,,,Outpatient,,,5.00,5.00,,2.94,58.75,,6.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,6.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,346.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.35,47,,336.52,Percent of Total Billed Charges,47% of Total Billed Charges,4.5,90,,3.6,Percent of Total Billed Charges,90% of Total Billed Charges,2.94,58.75,,6.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,336.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,336.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,4.5,
MACROBORE EXTN SET,6208723,CDM,270,RC,,,Outpatient,,,14.00,14.00,,8.23,58.75,,40.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.23,58.75,,40.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.78,48.41,,346.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,6.58,47,,336.52,Percent of Total Billed Charges,47% of Total Billed Charges,12.6,90,,10.08,Percent of Total Billed Charges,90% of Total Billed Charges,8.23,58.75,,40.888,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,336.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.58,47,,336.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,47,,5.264,Percent of Total Billed Charges,47% of Total Billed Charges,6.58,12.6,
CATH SECUREMENT,6208724,CDM,270,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,346.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,336.52,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,7.52,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,336.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,336.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
IV START SET,6208725,CDM,270,RC,,,Outpatient,,,9.10,9.10,,5.35,58.75,,9.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.35,58.75,,9.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.41,48.41,,346.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.19,90,,6.552,Percent of Total Billed Charges,90% of Total Billed Charges,8.19,90,,6.552,Percent of Total Billed Charges,90% of Total Billed Charges,4.28,47,,336.52,Percent of Total Billed Charges,47% of Total Billed Charges,8.19,90,,6.552,Percent of Total Billed Charges,90% of Total Billed Charges,5.35,58.75,,9.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.28,47,,336.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.28,47,,336.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.28,47,,3.424,Percent of Total Billed Charges,47% of Total Billed Charges,4.28,47,,3.424,Percent of Total Billed Charges,47% of Total Billed Charges,4.28,8.19,
ORAL MOUTH RELIEF,6208726,CDM,270,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,4.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,4.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,346.616,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,336.52,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,4.168,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,336.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,336.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
DEFIB PAD ADULTZOLL,6208727,CDM,270,RC,,,Outpatient,,,98.75,98.75,,58.02,58.75,,2.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.02,58.75,,2.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.8,48.41,,6.6,Percent of Total Billed Charges,48.41% of Total Billed Charges,88.88,90,,71.104,Percent of Total Billed Charges,90% of Total Billed Charges,88.88,90,,71.104,Percent of Total Billed Charges,90% of Total Billed Charges,46.41,47,,6.408,Percent of Total Billed Charges,47% of Total Billed Charges,88.88,90,,71.104,Percent of Total Billed Charges,90% of Total Billed Charges,58.02,58.75,,2.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.41,47,,6.408,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,46.41,47,,6.408,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,46.41,47,,37.128,Percent of Total Billed Charges,47% of Total Billed Charges,46.41,47,,37.128,Percent of Total Billed Charges,47% of Total Billed Charges,46.41,88.88,
DEFIB PAD PED ZOLL,6208728,CDM,270,RC,,,Outpatient,,,75.55,75.55,,44.39,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,44.39,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,36.57,48.41,,12.896,Percent of Total Billed Charges,48.41% of Total Billed Charges,68,90,,54.4,Percent of Total Billed Charges,90% of Total Billed Charges,68,90,,54.4,Percent of Total Billed Charges,90% of Total Billed Charges,35.51,47,,12.52,Percent of Total Billed Charges,47% of Total Billed Charges,68,90,,54.4,Percent of Total Billed Charges,90% of Total Billed Charges,44.39,58.75,,9.4,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.51,47,,12.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,35.51,47,,12.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,35.51,47,,28.408,Percent of Total Billed Charges,47% of Total Billed Charges,35.51,47,,28.408,Percent of Total Billed Charges,47% of Total Billed Charges,35.51,68,
CATH MALE EXTERNAL,6208729,CDM,270,RC,,,Outpatient,,,5.70,5.70,,3.35,58.75,,49.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.35,58.75,,49.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.76,48.41,,33.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.13,90,,4.104,Percent of Total Billed Charges,90% of Total Billed Charges,5.13,90,,4.104,Percent of Total Billed Charges,90% of Total Billed Charges,2.68,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,5.13,90,,4.104,Percent of Total Billed Charges,90% of Total Billed Charges,3.35,58.75,,49.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.68,47,,32.448,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.68,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.68,47,,2.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.68,47,,2.144,Percent of Total Billed Charges,47% of Total Billed Charges,2.68,5.13,
PHILLY CERV COLLAR,6208730,CDM,270,RC,,,Outpatient,,,22.00,22.00,,12.93,58.75,,93.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.93,58.75,,93.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.65,48.41,,4.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,10.34,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,19.8,90,,15.84,Percent of Total Billed Charges,90% of Total Billed Charges,12.93,58.75,,93.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,4.208,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.34,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,47,,8.272,Percent of Total Billed Charges,47% of Total Billed Charges,10.34,19.8,
OPTIFOAM DRESSING 3X3,6208731,CDM,270,RC,,,Outpatient,,,9.00,9.00,,5.29,58.75,,127.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.29,58.75,,127.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.36,48.41,,4.92,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.1,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,8.1,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,4.23,47,,4.776,Percent of Total Billed Charges,47% of Total Billed Charges,8.1,90,,6.48,Percent of Total Billed Charges,90% of Total Billed Charges,5.29,58.75,,127.368,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,4.776,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.23,47,,4.776,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.23,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,47,,3.384,Percent of Total Billed Charges,47% of Total Billed Charges,4.23,8.1,
HYDROGEL SKINTEGRITY 1 OZ,6208732,CDM,270,RC,,,Outpatient,,,5.50,5.50,,3.23,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.23,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.66,48.41,,15.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,2.59,47,,14.76,Percent of Total Billed Charges,47% of Total Billed Charges,4.95,90,,3.96,Percent of Total Billed Charges,90% of Total Billed Charges,3.23,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,14.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.59,47,,14.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.59,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,47,,2.072,Percent of Total Billed Charges,47% of Total Billed Charges,2.59,4.95,
OPTIFOAM DRESSING 4X4,6208733,CDM,270,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,14.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,14.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
OPTIFOAM DRESSING (MOIST),6208734,CDM,270,RC,,,Outpatient,,,9.20,9.20,,5.41,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.41,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.45,48.41,,33.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,8.28,90,,6.624,Percent of Total Billed Charges,90% of Total Billed Charges,8.28,90,,6.624,Percent of Total Billed Charges,90% of Total Billed Charges,4.32,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,8.28,90,,6.624,Percent of Total Billed Charges,90% of Total Billed Charges,5.41,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.32,47,,32.448,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.32,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.32,47,,3.456,Percent of Total Billed Charges,47% of Total Billed Charges,4.32,47,,3.456,Percent of Total Billed Charges,47% of Total Billed Charges,4.32,8.28,
ANTIMICRO SILVER SORB .25 OZ,6208735,CDM,270,RC,,,Outpatient,,,11.90,11.90,,6.99,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.99,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.76,48.41,,10.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.71,90,,8.568,Percent of Total Billed Charges,90% of Total Billed Charges,10.71,90,,8.568,Percent of Total Billed Charges,90% of Total Billed Charges,5.59,47,,10.432,Percent of Total Billed Charges,47% of Total Billed Charges,10.71,90,,8.568,Percent of Total Billed Charges,90% of Total Billed Charges,6.99,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.59,47,,10.432,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.59,47,,10.432,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.59,47,,4.472,Percent of Total Billed Charges,47% of Total Billed Charges,5.59,47,,4.472,Percent of Total Billed Charges,47% of Total Billed Charges,5.59,10.71,
REMEDY SKIN REPAIR 2 OZ,6208736,CDM,270,RC,,,Outpatient,,,10.00,10.00,,5.88,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.88,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.84,48.41,,14.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,9,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,9,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,9,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,5.88,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,14.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.7,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,9,
REMEDY SKINCARE REPAIR 4 OZ,6208737,CDM,270,RC,,,Outpatient,,,14.92,14.92,,8.77,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.77,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.22,48.41,,14.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.43,90,,10.744,Percent of Total Billed Charges,90% of Total Billed Charges,13.43,90,,10.744,Percent of Total Billed Charges,90% of Total Billed Charges,7.01,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,13.43,90,,10.744,Percent of Total Billed Charges,90% of Total Billed Charges,8.77,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.01,47,,14.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.01,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.01,47,,5.608,Percent of Total Billed Charges,47% of Total Billed Charges,7.01,47,,5.608,Percent of Total Billed Charges,47% of Total Billed Charges,7.01,13.43,
ALGINATE DRESSING 4X4 MAXORB E,6208738,CDM,270,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,1.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,1.52,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,1.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,1.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
BONE INJECTION GUN,6208739,CDM,270,RC,,,Outpatient,,,185.90,185.90,,109.22,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,109.22,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.99,48.41,,42.736,Percent of Total Billed Charges,48.41% of Total Billed Charges,167.31,90,,133.848,Percent of Total Billed Charges,90% of Total Billed Charges,167.31,90,,133.848,Percent of Total Billed Charges,90% of Total Billed Charges,87.37,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,167.31,90,,133.848,Percent of Total Billed Charges,90% of Total Billed Charges,109.22,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,87.37,47,,41.488,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,87.37,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,87.37,47,,69.896,Percent of Total Billed Charges,47% of Total Billed Charges,87.37,47,,69.896,Percent of Total Billed Charges,47% of Total Billed Charges,87.37,167.31,
DRESSING CHANGE TRAY,6208740,CDM,270,RC,,,Outpatient,,,6.46,6.46,,3.8,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.8,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.13,48.41,,42.736,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.81,90,,4.648,Percent of Total Billed Charges,90% of Total Billed Charges,5.81,90,,4.648,Percent of Total Billed Charges,90% of Total Billed Charges,3.04,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,5.81,90,,4.648,Percent of Total Billed Charges,90% of Total Billed Charges,3.8,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.04,47,,41.488,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.04,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.04,47,,2.432,Percent of Total Billed Charges,47% of Total Billed Charges,3.04,47,,2.432,Percent of Total Billed Charges,47% of Total Billed Charges,3.04,5.81,
GLUCERNA 8 OZ CAN,6208742,CDM,270,RC,,,Outpatient,,,3.95,3.95,,2.32,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.32,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.91,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,3.56,90,,2.848,Percent of Total Billed Charges,90% of Total Billed Charges,3.56,90,,2.848,Percent of Total Billed Charges,90% of Total Billed Charges,1.86,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,3.56,90,,2.848,Percent of Total Billed Charges,90% of Total Billed Charges,2.32,58.75,,165.44,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.86,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.86,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.86,47,,1.488,Percent of Total Billed Charges,47% of Total Billed Charges,1.86,47,,1.488,Percent of Total Billed Charges,47% of Total Billed Charges,1.86,3.56,
INTRAVIA 500 ML,6208743,CDM,270,RC,,,Outpatient,,,10.00,10.00,,5.88,58.75,,440.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.88,58.75,,440.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.84,48.41,,5.248,Percent of Total Billed Charges,48.41% of Total Billed Charges,9,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,9,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,47,,5.096,Percent of Total Billed Charges,47% of Total Billed Charges,9,90,,7.2,Percent of Total Billed Charges,90% of Total Billed Charges,5.88,58.75,,440.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,5.096,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.7,47,,5.096,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.7,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,47,,3.76,Percent of Total Billed Charges,47% of Total Billed Charges,4.7,9,
SMARTSITE ADAPTOR,6208744,CDM,270,RC,,,Outpatient,,,7.00,7.00,,4.11,58.75,,346.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.11,58.75,,346.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.39,48.41,,3.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,3.29,47,,3.456,Percent of Total Billed Charges,47% of Total Billed Charges,6.3,90,,5.04,Percent of Total Billed Charges,90% of Total Billed Charges,4.11,58.75,,346.624,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,3.456,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.29,47,,3.456,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,47,,2.632,Percent of Total Billed Charges,47% of Total Billed Charges,3.29,6.3,
PEG KIT,6208745,CDM,270,RC,,,Outpatient,,,121.80,121.80,,71.56,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,71.56,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,58.96,48.41,,15.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,109.62,90,,87.696,Percent of Total Billed Charges,90% of Total Billed Charges,109.62,90,,87.696,Percent of Total Billed Charges,90% of Total Billed Charges,57.25,47,,14.76,Percent of Total Billed Charges,47% of Total Billed Charges,109.62,90,,87.696,Percent of Total Billed Charges,90% of Total Billed Charges,71.56,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,57.25,47,,14.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,57.25,47,,14.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,57.25,47,,45.8,Percent of Total Billed Charges,47% of Total Billed Charges,57.25,47,,45.8,Percent of Total Billed Charges,47% of Total Billed Charges,57.25,109.62,
DISK FILTER 5 MICRON,6208746,CDM,270,RC,,,Outpatient,,,19.00,19.00,,11.16,58.75,,483.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.16,58.75,,483.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.2,48.41,,33.016,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,17.1,90,,13.68,Percent of Total Billed Charges,90% of Total Billed Charges,11.16,58.75,,483.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,32.056,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.93,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,47,,7.144,Percent of Total Billed Charges,47% of Total Billed Charges,8.93,17.1,
UNDERPADS EXTRA SORB 30X36,6208747,CDM,270,RC,,,Outpatient,,,3.00,3.00,,1.76,58.75,,1428.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.76,58.75,,1428.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.45,48.41,,33.016,Percent of Total Billed Charges,48.41% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,1.41,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,2.7,90,,2.16,Percent of Total Billed Charges,90% of Total Billed Charges,1.76,58.75,,1428.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,32.056,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.41,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.41,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,47,,1.128,Percent of Total Billed Charges,47% of Total Billed Charges,1.41,2.7,
TENA WIPES,6208748,CDM,270,RC,,,Outpatient,,,8.00,8.00,,4.7,58.75,,315.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.7,58.75,,315.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.87,48.41,,12.856,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,3.76,47,,12.48,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,90,,5.76,Percent of Total Billed Charges,90% of Total Billed Charges,4.7,58.75,,315.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,12.48,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.76,47,,12.48,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,47,,3.008,Percent of Total Billed Charges,47% of Total Billed Charges,3.76,7.2,
DRESSING ADHESIVE ISLAND TELFA,6208749,CDM,270,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,315.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,315.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,90.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,88.08,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,315.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,88.08,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,88.08,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
DRES PURACOL COLLAGEN WOUND4X4,6208750,CDM,270,RC,,,Outpatient,,,15.00,15.00,,8.81,58.75,,1298.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.81,58.75,,1298.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.26,48.41,,19.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,7.05,47,,19.16,Percent of Total Billed Charges,47% of Total Billed Charges,13.5,90,,10.8,Percent of Total Billed Charges,90% of Total Billed Charges,8.81,58.75,,1298.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,19.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.05,47,,19.16,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,47,,5.64,Percent of Total Billed Charges,47% of Total Billed Charges,7.05,13.5,
TROCAR CATHETER 24 FR,6208751,CDM,270,RC,,,Outpatient,,,27.60,27.60,,16.22,58.75,,315.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.22,58.75,,315.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.36,48.41,,19.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,24.84,90,,19.872,Percent of Total Billed Charges,90% of Total Billed Charges,24.84,90,,19.872,Percent of Total Billed Charges,90% of Total Billed Charges,12.97,47,,19.16,Percent of Total Billed Charges,47% of Total Billed Charges,24.84,90,,19.872,Percent of Total Billed Charges,90% of Total Billed Charges,16.22,58.75,,315.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.97,47,,19.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,12.97,47,,19.16,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,12.97,47,,10.376,Percent of Total Billed Charges,47% of Total Billed Charges,12.97,47,,10.376,Percent of Total Billed Charges,47% of Total Billed Charges,12.97,24.84,
ALLEVYN GENTLE BORDER,6208752,CDM,270,RC,,,Outpatient,,,6.00,6.00,,3.53,58.75,,315.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,315.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,9.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,2.82,47,,9.216,Percent of Total Billed Charges,47% of Total Billed Charges,5.4,90,,4.32,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,58.75,,315.112,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,9.216,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,9.216,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,5.4,
IODOFORM 2,6208753,CDM,270,RC,,,Outpatient,,,11.75,11.75,,6.9,58.75,,169.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.9,58.75,,169.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.69,48.41,,12.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,10.58,90,,8.464,Percent of Total Billed Charges,90% of Total Billed Charges,10.58,90,,8.464,Percent of Total Billed Charges,90% of Total Billed Charges,5.52,47,,12.576,Percent of Total Billed Charges,47% of Total Billed Charges,10.58,90,,8.464,Percent of Total Billed Charges,90% of Total Billed Charges,6.9,58.75,,169.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.52,47,,12.576,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.52,47,,12.576,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.52,47,,4.416,Percent of Total Billed Charges,47% of Total Billed Charges,5.52,47,,4.416,Percent of Total Billed Charges,47% of Total Billed Charges,5.52,10.58,
PLAIN PKG 2,6208754,CDM,270,RC,,,Outpatient,,,10.35,10.35,,6.08,58.75,,186.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.08,58.75,,186.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.01,48.41,,4.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.32,90,,7.456,Percent of Total Billed Charges,90% of Total Billed Charges,9.32,90,,7.456,Percent of Total Billed Charges,90% of Total Billed Charges,4.86,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,9.32,90,,7.456,Percent of Total Billed Charges,90% of Total Billed Charges,6.08,58.75,,186.688,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.86,47,,4.208,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.86,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.86,47,,3.888,Percent of Total Billed Charges,47% of Total Billed Charges,4.86,47,,3.888,Percent of Total Billed Charges,47% of Total Billed Charges,4.86,9.32,
BLOOD PRESSURE ANEROID HANDHLD,6208755,CDM,270,RC,,,Outpatient,,,31.05,31.05,,18.24,58.75,,214.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.24,58.75,,214.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.03,48.41,,3.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,27.95,90,,22.36,Percent of Total Billed Charges,90% of Total Billed Charges,27.95,90,,22.36,Percent of Total Billed Charges,90% of Total Billed Charges,14.59,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,27.95,90,,22.36,Percent of Total Billed Charges,90% of Total Billed Charges,18.24,58.75,,214.792,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.59,47,,3.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.59,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.59,47,,11.672,Percent of Total Billed Charges,47% of Total Billed Charges,14.59,47,,11.672,Percent of Total Billed Charges,47% of Total Billed Charges,14.59,27.95,
BLOOD/FLUID WARMING SYSTEM,6208756,CDM,270,RC,,,Outpatient,,,19.50,19.50,,11.46,58.75,,283.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.46,58.75,,283.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.44,48.41,,3.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,17.55,90,,14.04,Percent of Total Billed Charges,90% of Total Billed Charges,17.55,90,,14.04,Percent of Total Billed Charges,90% of Total Billed Charges,9.17,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,17.55,90,,14.04,Percent of Total Billed Charges,90% of Total Billed Charges,11.46,58.75,,283.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.17,47,,3.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.17,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.17,47,,7.336,Percent of Total Billed Charges,47% of Total Billed Charges,9.17,47,,7.336,Percent of Total Billed Charges,47% of Total Billed Charges,9.17,17.55,
IODOFLEX,6208757,CDM,270,RC,,,Outpatient,,,15.20,15.20,,8.93,58.75,,312.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.93,58.75,,312.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.36,48.41,,42.736,Percent of Total Billed Charges,48.41% of Total Billed Charges,13.68,90,,10.944,Percent of Total Billed Charges,90% of Total Billed Charges,13.68,90,,10.944,Percent of Total Billed Charges,90% of Total Billed Charges,7.14,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,13.68,90,,10.944,Percent of Total Billed Charges,90% of Total Billed Charges,8.93,58.75,,312.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.14,47,,41.488,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.14,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.14,47,,5.712,Percent of Total Billed Charges,47% of Total Billed Charges,7.14,47,,5.712,Percent of Total Billed Charges,47% of Total Billed Charges,7.14,13.68,
SPLINT FINGER STAX SZ 1-6,6208758,CDM,270,RC,,,Outpatient,,,13.90,13.90,,8.17,58.75,,183.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.17,58.75,,183.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.73,48.41,,42.736,Percent of Total Billed Charges,48.41% of Total Billed Charges,12.51,90,,10.008,Percent of Total Billed Charges,90% of Total Billed Charges,12.51,90,,10.008,Percent of Total Billed Charges,90% of Total Billed Charges,6.53,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,12.51,90,,10.008,Percent of Total Billed Charges,90% of Total Billed Charges,8.17,58.75,,183.816,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.53,47,,41.488,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.53,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.53,47,,5.224,Percent of Total Billed Charges,47% of Total Billed Charges,6.53,47,,5.224,Percent of Total Billed Charges,47% of Total Billed Charges,6.53,12.51,
RETAINER KIT TUBULAR MULTIPURP,6208759,CDM,270,RC,,,Outpatient,,,21.45,21.45,,12.6,58.75,,205.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.6,58.75,,205.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.38,48.41,,14.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.31,90,,15.448,Percent of Total Billed Charges,90% of Total Billed Charges,19.31,90,,15.448,Percent of Total Billed Charges,90% of Total Billed Charges,10.08,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,19.31,90,,15.448,Percent of Total Billed Charges,90% of Total Billed Charges,12.6,58.75,,205.392,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.08,47,,14.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.08,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.08,47,,8.064,Percent of Total Billed Charges,47% of Total Billed Charges,10.08,47,,8.064,Percent of Total Billed Charges,47% of Total Billed Charges,10.08,19.31,
Quik Clot,6208763,CDM,270,RC,,,Outpatient,,,35.25,35.25,,20.71,58.75,,236.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,20.71,58.75,,236.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.06,48.41,,33.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,31.73,90,,25.384,Percent of Total Billed Charges,90% of Total Billed Charges,31.73,90,,25.384,Percent of Total Billed Charges,90% of Total Billed Charges,16.57,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,31.73,90,,25.384,Percent of Total Billed Charges,90% of Total Billed Charges,20.71,58.75,,236.408,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.57,47,,32.448,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,16.57,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,16.57,47,,13.256,Percent of Total Billed Charges,47% of Total Billed Charges,16.57,47,,13.256,Percent of Total Billed Charges,47% of Total Billed Charges,16.57,31.73,
Bougie Introducer,6208764,CDM,270,RC,,,Outpatient,,,21.50,21.50,,12.63,58.75,,312.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.63,58.75,,312.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.41,48.41,,33.016,Percent of Total Billed Charges,48.41% of Total Billed Charges,19.35,90,,15.48,Percent of Total Billed Charges,90% of Total Billed Charges,19.35,90,,15.48,Percent of Total Billed Charges,90% of Total Billed Charges,10.11,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,19.35,90,,15.48,Percent of Total Billed Charges,90% of Total Billed Charges,12.63,58.75,,312.128,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.11,47,,32.056,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,10.11,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,10.11,47,,8.088,Percent of Total Billed Charges,47% of Total Billed Charges,10.11,47,,8.088,Percent of Total Billed Charges,47% of Total Billed Charges,10.11,19.35,
Pelvic Sling,6208765,CDM,270,RC,,,Outpatient,,,110.60,110.60,,64.98,58.75,,343.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.98,58.75,,343.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,53.54,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,99.54,90,,79.632,Percent of Total Billed Charges,90% of Total Billed Charges,99.54,90,,79.632,Percent of Total Billed Charges,90% of Total Billed Charges,51.98,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,99.54,90,,79.632,Percent of Total Billed Charges,90% of Total Billed Charges,64.98,58.75,,343.568,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,51.98,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,51.98,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,51.98,47,,41.584,Percent of Total Billed Charges,47% of Total Billed Charges,51.98,47,,41.584,Percent of Total Billed Charges,47% of Total Billed Charges,51.98,99.54,
Laryngoscope Handle,6208766,CDM,270,RC,,,Outpatient,,,13.20,13.20,,7.76,58.75,,1048.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.76,58.75,,1048.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.39,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.88,90,,9.504,Percent of Total Billed Charges,90% of Total Billed Charges,11.88,90,,9.504,Percent of Total Billed Charges,90% of Total Billed Charges,6.2,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,11.88,90,,9.504,Percent of Total Billed Charges,90% of Total Billed Charges,7.76,58.75,,1048.032,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.2,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.2,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.2,47,,4.96,Percent of Total Billed Charges,47% of Total Billed Charges,6.2,47,,4.96,Percent of Total Billed Charges,47% of Total Billed Charges,6.2,11.88,
Stop The Bleed,6208767,CDM,270,RC,,,Outpatient,,,87.00,87.00,,51.11,58.75,,5.016,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.11,58.75,,5.016,Percent of Total Billed Charges,58.75% of Total Billed Charges,42.12,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,78.3,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,78.3,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,40.89,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,78.3,90,,62.64,Percent of Total Billed Charges,90% of Total Billed Charges,51.11,58.75,,5.016,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.89,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.89,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.89,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,40.89,47,,32.712,Percent of Total Billed Charges,47% of Total Billed Charges,40.89,78.3,
Disp. Pulse Ox Probe,6208768,CDM,270,RC,,,Outpatient,,,16.00,16.00,,9.4,58.75,,420.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.4,58.75,,420.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.75,48.41,,4.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,14.4,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,14.4,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,7.52,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,14.4,90,,11.52,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,58.75,,420.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.52,47,,4.208,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,7.52,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,7.52,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,7.52,47,,6.016,Percent of Total Billed Charges,47% of Total Billed Charges,7.52,14.4,
Picc Line Dressing Kit,6208769,CDM,270,RC,,,Outpatient,,,20.56,20.56,,12.08,58.75,,420.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,12.08,58.75,,420.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.95,48.41,,12.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,18.5,90,,14.8,Percent of Total Billed Charges,90% of Total Billed Charges,18.5,90,,14.8,Percent of Total Billed Charges,90% of Total Billed Charges,9.66,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,18.5,90,,14.8,Percent of Total Billed Charges,90% of Total Billed Charges,12.08,58.75,,420.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.66,47,,11.976,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.66,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.66,47,,7.728,Percent of Total Billed Charges,47% of Total Billed Charges,9.66,47,,7.728,Percent of Total Billed Charges,47% of Total Billed Charges,9.66,18.5,
Stat Lock,6208770,CDM,270,RC,,,Outpatient,,,8.86,8.86,,5.21,58.75,,420.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.21,58.75,,420.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.29,48.41,,12.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,7.97,90,,6.376,Percent of Total Billed Charges,90% of Total Billed Charges,7.97,90,,6.376,Percent of Total Billed Charges,90% of Total Billed Charges,4.16,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,7.97,90,,6.376,Percent of Total Billed Charges,90% of Total Billed Charges,5.21,58.75,,420.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.16,47,,11.976,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.16,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.16,47,,3.328,Percent of Total Billed Charges,47% of Total Billed Charges,4.16,47,,3.328,Percent of Total Billed Charges,47% of Total Billed Charges,4.16,7.97,
Disp. Blood Pressure Cuff,6208771,CDM,270,RC,,,Outpatient,,,4.84,4.84,,2.84,58.75,,420.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.84,58.75,,420.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.34,48.41,,12.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,4.36,90,,3.488,Percent of Total Billed Charges,90% of Total Billed Charges,4.36,90,,3.488,Percent of Total Billed Charges,90% of Total Billed Charges,2.27,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,4.36,90,,3.488,Percent of Total Billed Charges,90% of Total Billed Charges,2.84,58.75,,420.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.27,47,,11.976,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.27,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.27,47,,1.816,Percent of Total Billed Charges,47% of Total Billed Charges,2.27,47,,1.816,Percent of Total Billed Charges,47% of Total Billed Charges,2.27,4.36,
Two Flex,6208772,CDM,270,RC,,,Outpatient,,,20.00,20.00,,11.75,58.75,,420.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.75,58.75,,420.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,9.68,48.41,,3.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,9.4,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,18,90,,14.4,Percent of Total Billed Charges,90% of Total Billed Charges,11.75,58.75,,420.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,3.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,9.4,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,47,,7.52,Percent of Total Billed Charges,47% of Total Billed Charges,9.4,18,
LUMBAR S SUPPORT,7000366,CDM,270,RC,,,Outpatient,,,106.00,106.00,,62.28,58.75,,8.016,Percent of Total Billed Charges,58.75% of Total Billed Charges,62.28,58.75,,8.016,Percent of Total Billed Charges,58.75% of Total Billed Charges,51.31,48.41,,3.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,95.4,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,95.4,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,49.82,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,95.4,90,,76.32,Percent of Total Billed Charges,90% of Total Billed Charges,62.28,58.75,,8.016,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.82,47,,3.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,49.82,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.82,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,49.82,47,,39.856,Percent of Total Billed Charges,47% of Total Billed Charges,49.82,95.4,
UH OV Est Mod Complexity,7000373,CDM,905,RC,99214,HCPCS,Outpatient,,,199.00,199.00,,116.91,58.75,,15.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,116.91,58.75,,15.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,96.34,48.41,,40.512,Percent of Total Billed Charges,48.41% of Total Billed Charges,108,100,,,fee Schedule,100% of BCBS fee schedule,108,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,93.53,47,,39.328,Percent of Total Billed Charges,47% of Total Billed Charges,108,100,,,Fee Schedule,100% of BCBS PPO fee schedule,116.91,58.75,,15.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,93.53,47,,39.328,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,93.53,47,,39.328,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,100.86,115,,80.688,Percent of Total Billed Charges,115% of Total Billed Charges,100.86,115,,,Case Rate,Pays based on per visit rate,93.53,116.91,
UH OV New. Mod Complex,7000374,CDM,905,RC,99204,HCPCS,Outpatient,,,271.00,271.00,,159.21,58.75,,40.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,159.21,58.75,,40.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,131.19,48.41,,424.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,125.88,100,,,fee Schedule,100% of BCBS fee schedule,125.88,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,127.37,47,,411.72,Percent of Total Billed Charges,47% of Total Billed Charges,125.88,100,,,Fee Schedule,100% of BCBS PPO fee schedule,159.21,58.75,,40.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,127.37,47,,411.72,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,127.37,47,,411.72,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,138.13,115,,110.504,Percent of Total Billed Charges,115% of Total Billed Charges,138.13,115,,,Case Rate,Pays based on per visit rate,125.88,159.21,
UH IND PSYCH 45-50MIN,7000375,CDM,905,RC,90834,HCPCS,Outpatient,,,352.00,352.00,,206.8,58.75,,5.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,206.8,58.75,,5.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,170.4,48.41,,385.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,126.11,100,,,fee Schedule,100% of BCBS fee schedule,126.11,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,165.44,47,,374.12,Percent of Total Billed Charges,47% of Total Billed Charges,126.11,100,,,Fee Schedule,100% of BCBS PPO fee schedule,206.8,58.75,,5.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,165.44,47,,374.12,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,165.44,47,,374.12,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,102.02,115,,81.616,Percent of Total Billed Charges,115% of Total Billed Charges,102.02,115,,,Case Rate,Pays based on per visit rate,102.02,206.8,
UH IND PSYCH 20-30MIN,7000376,CDM,905,RC,90832,HCPCS,Outpatient,,,352.00,352.00,,206.8,58.75,,5.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,206.8,58.75,,5.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,170.4,48.41,,1034.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,126.11,100,,,fee Schedule,100% of BCBS fee schedule,126.11,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,165.44,47,,1004.296,Percent of Total Billed Charges,47% of Total Billed Charges,126.11,100,,,Fee Schedule,100% of BCBS PPO fee schedule,206.8,58.75,,5.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,165.44,47,,1004.296,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,165.44,47,,1004.296,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.31,115,,61.848,Percent of Total Billed Charges,115% of Total Billed Charges,77.31,115,,,Case Rate,Pays based on per visit rate,77.31,206.8,
IND PSYCH 20-30MIN,7000377,CDM,914,RC,90832,HCPCS,Outpatient,,,352.00,352.00,,206.8,58.75,,18.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,206.8,58.75,,18.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,170.4,48.41,,385.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,126.11,100,,,fee Schedule,100% of BCBS fee schedule,126.11,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,165.44,47,,374.12,Percent of Total Billed Charges,47% of Total Billed Charges,126.11,100,,,Fee Schedule,100% of BCBS PPO fee schedule,206.8,58.75,,18.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,165.44,47,,374.12,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,165.44,47,,374.12,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,77.31,115,,61.848,Percent of Total Billed Charges,115% of Total Billed Charges,77.31,115,,,Case Rate,Pays based on per visit rate,77.31,206.8,
IND PSYCH 45-50MIN,7000378,CDM,914,RC,90834,HCPCS,Outpatient,,,352.00,352.00,,206.8,58.75,,18.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,206.8,58.75,,18.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,170.4,48.41,,385.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,126.11,100,,,fee Schedule,100% of BCBS fee schedule,126.11,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,165.44,47,,374.12,Percent of Total Billed Charges,47% of Total Billed Charges,126.11,100,,,Fee Schedule,100% of BCBS PPO fee schedule,206.8,58.75,,18.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,165.44,47,,374.12,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,165.44,47,,374.12,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,102.02,115,,81.616,Percent of Total Billed Charges,115% of Total Billed Charges,102.02,115,,,Case Rate,Pays based on per visit rate,102.02,206.8,
FAM THER W/PATIENT,7000379,CDM,916,RC,90847,HCPCS,Outpatient,,,352.00,352.00,,206.8,58.75,,40.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,206.8,58.75,,40.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,170.4,48.41,,6.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,126.11,100,,,fee Schedule,100% of BCBS fee schedule,126.11,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,165.44,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,126.11,100,,,Fee Schedule,100% of BCBS PPO fee schedule,206.8,58.75,,40.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,165.44,47,,6.768,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,165.44,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,114.91,115,,91.928,Percent of Total Billed Charges,115% of Total Billed Charges,114.91,115,,,Case Rate,Pays based on per visit rate,114.91,206.8,
FAM THER W/O PATIENT,7000380,CDM,916,RC,90846,HCPCS,Outpatient,,,352.00,352.00,,206.8,58.75,,13.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,206.8,58.75,,13.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,170.4,48.41,,6.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,126.11,100,,,fee Schedule,100% of BCBS fee schedule,126.11,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,165.44,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,126.11,100,,,Fee Schedule,100% of BCBS PPO fee schedule,206.8,58.75,,13.04,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,165.44,47,,6.768,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,165.44,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,110.18,115,,88.144,Percent of Total Billed Charges,115% of Total Billed Charges,110.18,115,,,Case Rate,Pays based on per visit rate,110.18,206.8,
GRP PSYCH,7000381,CDM,915,RC,90853,HCPCS,Outpatient,,,352.00,352.00,,206.8,58.75,,18.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,206.8,58.75,,18.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,170.4,48.41,,42.608,Percent of Total Billed Charges,48.41% of Total Billed Charges,75.4,100,,,fee Schedule,100% of BCBS fee schedule,75.4,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,165.44,47,,41.368,Percent of Total Billed Charges,47% of Total Billed Charges,75.4,100,,,Fee Schedule,100% of BCBS PPO fee schedule,206.8,58.75,,18.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,165.44,47,,41.368,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,165.44,47,,41.368,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.12,115,,21.696,Percent of Total Billed Charges,115% of Total Billed Charges,27.12,115,,,Case Rate,Pays based on per visit rate,27.12,206.8,
EDUCATION/TRAINING,7000382,CDM,915,RC,90853,HCPCS,Outpatient,,,352.00,352.00,,206.8,58.75,,18.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,206.8,58.75,,18.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,170.4,48.41,,45.312,Percent of Total Billed Charges,48.41% of Total Billed Charges,75.4,100,,,fee Schedule,100% of BCBS fee schedule,75.4,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,165.44,47,,43.992,Percent of Total Billed Charges,47% of Total Billed Charges,75.4,100,,,Fee Schedule,100% of BCBS PPO fee schedule,206.8,58.75,,18.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,165.44,47,,43.992,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,165.44,47,,43.992,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.12,115,,21.696,Percent of Total Billed Charges,115% of Total Billed Charges,27.12,115,,,Case Rate,Pays based on per visit rate,27.12,206.8,
UH GRP PSYCH,7000383,CDM,905,RC,90853,HCPCS,Outpatient,,,352.00,352.00,,206.8,58.75,,1.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,206.8,58.75,,1.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,170.4,48.41,,438.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,75.4,100,,,fee Schedule,100% of BCBS fee schedule,75.4,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,165.44,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,75.4,100,,,Fee Schedule,100% of BCBS PPO fee schedule,206.8,58.75,,1.904,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,165.44,47,,425.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,165.44,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.12,115,,21.696,Percent of Total Billed Charges,115% of Total Billed Charges,27.12,115,,,Case Rate,Pays based on per visit rate,27.12,206.8,
PSYCHO EDUCATION,7000384,CDM,915,RC,90853,HCPCS,Outpatient,,,352.00,352.00,,206.8,58.75,,51.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,206.8,58.75,,51.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,170.4,48.41,,438.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,75.4,100,,,fee Schedule,100% of BCBS fee schedule,75.4,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,165.44,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,75.4,100,,,Fee Schedule,100% of BCBS PPO fee schedule,206.8,58.75,,51.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,165.44,47,,425.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,165.44,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.12,115,,21.696,Percent of Total Billed Charges,115% of Total Billed Charges,27.12,115,,,Case Rate,Pays based on per visit rate,27.12,206.8,
OV New. Mod Complex,7000385,CDM,961,RC,99204,HCPCS,Outpatient,,,271.00,271.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
OV Est Mod Complexity,7000386,CDM,961,RC,99214,HCPCS,Outpatient,,,199.00,199.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
Psych. Diag. Eval. w/ Med,7000387,CDM,961,RC,90792,HCPCS,Outpatient,,,361.30,361.30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
Pharmacologic Mgmt w/Psy.,7000388,CDM,961,RC,90863,HCPCS,Outpatient,,,68.25,68.25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
DEBRIDE SKIN PARTIAL,9000000,CDM,361,RC,,,Outpatient,,,937.50,937.50,,550.78,58.75,,18.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,550.78,58.75,,18.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,453.84,48.41,,3459.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,843.75,90,,675,Percent of Total Billed Charges,90% of Total Billed Charges,843.75,90,,675,Percent of Total Billed Charges,90% of Total Billed Charges,440.63,47,,3358.76,Percent of Total Billed Charges,47% of Total Billed Charges,843.75,90,,675,Percent of Total Billed Charges,90% of Total Billed Charges,550.78,58.75,,18.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,440.63,47,,3358.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,440.63,47,,3358.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,440.63,47,,352.504,Percent of Total Billed Charges,47% of Total Billed Charges,440.63,47,,352.504,Percent of Total Billed Charges,47% of Total Billed Charges,440.63,843.75,
"DEBRIDE SKIN, FULL",9000001,CDM,361,RC,,,Outpatient,,,737.50,737.50,,433.28,58.75,,40.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,433.28,58.75,,40.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,357.02,48.41,,1931.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,663.75,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,663.75,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,346.63,47,,1875.608,Percent of Total Billed Charges,47% of Total Billed Charges,663.75,90,,531,Percent of Total Billed Charges,90% of Total Billed Charges,433.28,58.75,,40.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,346.63,47,,1875.608,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,346.63,47,,1875.608,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,346.63,47,,277.304,Percent of Total Billed Charges,47% of Total Billed Charges,346.63,47,,277.304,Percent of Total Billed Charges,47% of Total Billed Charges,346.63,663.75,
DEBRID SKIN INTO SUB,9000002,CDM,360,RC,11042,HCPCS,Outpatient,,,1132.20,1132.20,,665.17,58.75,,40.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,665.17,58.75,,40.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,548.1,48.41,,1931.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,,Fee Schedule,100% of ASC Tier Groupings,532.13,47,,1875.608,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,,Fee Schedule,100% of ASC Tier Groupings,665.17,58.75,,40.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,532.13,47,,1875.608,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,532.13,47,,1875.608,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,61.82,115,,,Fee Schedule,115% of CMS OPPS Rate,61.82,115,,,Fee Schedule,115% of CMS OPPS Rate,61.82,665.17,
DEBRID SKIN INTO MUS,9000003,CDM,361,RC,11043,HCPCS,Outpatient,,,1029.25,1029.25,,604.68,58.75,,15.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,604.68,58.75,,15.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,498.26,48.41,,1931.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,543.2,100,,,fee Schedule,100% of ASC Tier Groupings ,543.2,100,,,Fee Schedule,100% of ASC Tier Groupings,483.75,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,543.2,100,,,Fee Schedule,100% of ASC Tier Groupings,604.68,58.75,,15.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,220.47,100,,,Fee Schedule,100% of ASC Tier Groupings,483.75,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed charges,220.47,100,,,Fee Schedule,100% ASC Tier Groupings,483.75,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,156.5,115,,,Fee Schedule,115% of CMS OPPS Rate,156.5,115,,,Fee Schedule,115% of CMS OPPS Rate,156.5,604.68,
DEBRID SKIN INTO BON,9000004,CDM,361,RC,11044,HCPCS,Outpatient,,,3040.00,3040.00,,1786,58.75,,110.096,Percent of Total Billed Charges,58.75% of Total Billed Charges,1786,58.75,,110.096,Percent of Total Billed Charges,58.75% of Total Billed Charges,1471.66,48.41,,1931.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,1500.8,100,,,fee Schedule,100% of ASC Tier Groupings ,1500.8,100,,,Fee Schedule,100% of ASC Tier Groupings,1428.8,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,1500.8,100,,,Fee Schedule,100% of ASC Tier Groupings,1786,58.75,,110.096,Percent of Total Billed Charges,58.75% of Total Billed Charges,494.68,100,,,Fee Schedule,100% of ASC Tier Groupings,1428.8,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed charges,494.68,100,,,Fee Schedule,100% ASC Tier Groupings,1428.8,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,475,100,,,Fee Schedule,100% of ASC Tier Groupings,228.51,115,,,Fee Schedule,115% of CMS OPPS Rate,228.51,115,,,Fee Schedule,115% of CMS OPPS Rate,228.51,1786,
I&D ABSCESS SIMPLE,9000005,CDM,361,RC,10060,HCPCS,Outpatient,,,670.45,670.45,,393.89,58.75,,23.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,393.89,58.75,,23.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,324.56,48.41,,438.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,315.11,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,393.89,58.75,,23.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.17,100,,,Fee Schedule,100% of ASC Tier Groupings,315.11,47,,425.704,Percent of Total Billed Charges,47% of Total Billed charges,64.17,100,,,Fee Schedule,100% ASC Tier Groupings,315.11,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,108.34,115,,,Fee Schedule,115% of CMS OPPS Rate,108.34,115,,,Fee Schedule,115% of CMS OPPS Rate,64.17,462,
PUNCH BIOPSY SKN SUB,9000006,CDM,361,RC,11100,HCPCS,Outpatient,,,670.45,670.45,,393.89,58.75,,23.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,393.89,58.75,,23.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,324.56,48.41,,438.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,603.41,90,,482.728,Percent of Total Billed Charges,90% of Total Billed Charges,603.41,90,,482.728,Percent of Total Billed Charges,90% of Total Billed Charges,315.11,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,603.41,90,,482.728,Percent of Total Billed Charges,90% of Total Billed Charges,393.89,58.75,,23.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,315.11,47,,425.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,315.11,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,315.11,47,,252.088,Percent of Total Billed Charges,47% of Total Billed Charges,315.11,47,,252.088,Percent of Total Billed Charges,47% of Total Billed Charges,315.11,603.41,
"I&D HEM,SER,FLUID CO",9000007,CDM,361,RC,10140,HCPCS,Outpatient,,,2763.45,2763.45,,1623.53,58.75,,11.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,1623.53,58.75,,11.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,1337.79,48.41,,438.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,1500.8,100,,,fee Schedule,100% of ASC Tier Groupings ,1500.8,100,,,Fee Schedule,100% of ASC Tier Groupings,1298.82,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,1500.8,100,,,Fee Schedule,100% of ASC Tier Groupings,1623.53,58.75,,11.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,89.57,100,,,Fee Schedule,100% of ASC Tier Groupings,1298.82,47,,425.704,Percent of Total Billed Charges,47% of Total Billed charges,89.57,100,,,Fee Schedule,100% ASC Tier Groupings,1298.82,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,620,100,,,Fee Schedule,100% of ASC Tier Groupings,120.72,115,,,Fee Schedule,115% of CMS OPPS Rate,120.72,115,,,Fee Schedule,115% of CMS OPPS Rate,89.57,1623.53,
CHEM CAUTR GRANTISS,9000008,CDM,361,RC,17250,HCPCS,Outpatient,,,670.45,670.45,,393.89,58.75,,15.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,393.89,58.75,,15.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,324.56,48.41,,438.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,315.11,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,393.89,58.75,,15.72,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,315.11,47,,425.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,315.11,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,37.86,115,,,Fee Schedule,115% of CMS OPPS Rate,37.86,115,,,Fee Schedule,115% of CMS OPPS Rate,37.86,462,
APPLCTION UNNA BOOT,9000009,CDM,510,RC,29580,HCPCS,Outpatient,,,670.45,670.45,,393.89,58.75,,5.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,393.89,58.75,,5.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,324.56,48.41,,438.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,146.72,100,,,fee Schedule,100% of ASC Tier Groupings ,146.72,100,,,Fee Schedule,100% of ASC Tier Groupings,315.11,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,146.72,100,,,Fee Schedule,100% of ASC Tier Groupings,393.89,58.75,,5.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,34.68,100,,,Fee Schedule,100% of ASC Tier Groupings,315.11,47,,425.704,Percent of Total Billed Charges,47% of Total Billed charges,34.68,100,,,Fee Schedule,100% ASC Tier Groupings,315.11,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,27.05,115,,,Fee Schedule,115% of CMS OPPS Rate,27.05,115,,,Fee Schedule,115% of CMS OPPS Rate,27.05,393.89,
NEW PT VISIT LEVEL I,9000010,CDM,510,RC,99201,HCPCS,Outpatient,,,361.10,361.10,,212.15,58.75,,4.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,212.15,58.75,,4.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,174.81,48.41,,398.608,Percent of Total Billed Charges,48.41% of Total Billed Charges,324.99,90,,259.992,Percent of Total Billed Charges,90% of Total Billed Charges,324.99,90,,259.992,Percent of Total Billed Charges,90% of Total Billed Charges,169.72,47,,387,Percent of Total Billed Charges,47% of Total Billed Charges,324.99,90,,259.992,Percent of Total Billed Charges,90% of Total Billed Charges,212.15,58.75,,4.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,169.72,47,,387,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,169.72,47,,387,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,169.72,47,,135.776,Percent of Total Billed Charges,47% of Total Billed Charges,169.72,47,,135.776,Percent of Total Billed Charges,47% of Total Billed Charges,169.72,324.99,
NEW PT VST LEVEL II,9000011,CDM,510,RC,99202,HCPCS,Outpatient,,,397.20,397.20,,233.36,58.75,,4.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,233.36,58.75,,4.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,192.28,48.41,,1070.232,Percent of Total Billed Charges,48.41% of Total Billed Charges,49.05,100,,,fee Schedule,100% of BCBS fee schedule,49.05,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,186.68,47,,1039.056,Percent of Total Billed Charges,47% of Total Billed Charges,49.05,100,,,Fee Schedule,100% of BCBS PPO fee schedule,233.36,58.75,,4.632,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,186.68,47,,1039.056,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,186.68,47,,1039.056,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,48.74,115,,,Fee Schedule,115% of CMS OPPS Rate,48.74,115,,,Fee Schedule,115% of CMS OPPS Rate,48.74,233.36,
NEW PT VST LEVEL III,9000012,CDM,510,RC,99203,HCPCS,Outpatient,,,457.00,457.00,,268.49,58.75,,51.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,268.49,58.75,,51.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,221.23,48.41,,2.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,73.58,100,,,fee Schedule,100% of BCBS fee schedule,73.58,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,214.79,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,73.58,100,,,Fee Schedule,100% of BCBS PPO fee schedule,268.49,58.75,,51.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,214.79,47,,2.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,214.79,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,84.66,115,,,Fee Schedule,115% of CMS OPPS Rate,84.66,115,,,Fee Schedule,115% of CMS OPPS Rate,73.58,268.49,
NEW PT VST LEVEL IV,9000013,CDM,510,RC,99204,HCPCS,Outpatient,,,603.75,603.75,25,354.7,58.75,,51.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,354.7,58.75,,51.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,292.28,48.41,,2.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,125.88,100,,,fee Schedule,100% of BCBS fee schedule,125.88,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,283.76,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,125.88,100,,,Fee Schedule,100% of BCBS PPO fee schedule,354.7,58.75,,51.864,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,283.76,47,,2.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,283.76,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,138.13,115,,,Fee Schedule,115% of CMS OPPS Rate,138.13,115,,,Fee Schedule,115% of CMS OPPS Rate,125.88,354.7,
NEW PT VST LEVEL V,9000014,CDM,510,RC,99205,HCPCS,Outpatient,,,664.10,664.10,,390.16,58.75,,18.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,390.16,58.75,,18.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,321.49,48.41,,10.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,164.48,100,,,fee Schedule,100% of BCBS fee schedule,164.48,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,312.13,47,,10.4,Percent of Total Billed Charges,47% of Total Billed Charges,164.48,100,,,Fee Schedule,100% of BCBS PPO fee schedule,390.16,58.75,,18.144,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,312.13,47,,10.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,312.13,47,,10.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,187.61,115,,,Fee Schedule,115% of CMS OPPS Rate,187.61,115,,,Fee Schedule,115% of CMS OPPS Rate,164.48,390.16,
EST PT VT LEVELI,9000015,CDM,510,RC,99211,HCPCS,Outpatient,,,391.10,391.10,,229.77,58.75,,40.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,229.77,58.75,,40.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,189.33,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,22.49,100,,,fee Schedule,100% of BCBS fee schedule,22.49,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,183.82,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,22.49,100,,,Fee Schedule,100% of BCBS PPO fee schedule,229.77,58.75,,40.56,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,183.82,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,183.82,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,9.12,115,,,Fee Schedule,115% of CMS OPPS Rate,9.12,115,,,Fee Schedule,115% of CMS OPPS Rate,9.12,229.77,
EST PT VT LEVELII,9000016,CDM,510,RC,99212,HCPCS,Outpatient,,,437.00,437.00,,256.74,58.75,,40.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,256.74,58.75,,40.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,211.55,48.41,,10.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,44.45,100,,,fee Schedule,100% of BCBS fee schedule,44.45,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,205.39,47,,10.568,Percent of Total Billed Charges,47% of Total Billed Charges,44.45,100,,,Fee Schedule,100% of BCBS PPO fee schedule,256.74,58.75,,40.064,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,205.39,47,,10.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,205.39,47,,10.568,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,36.59,115,,,Fee Schedule,115% of CMS OPPS Rate,36.59,115,,,Fee Schedule,115% of CMS OPPS Rate,36.59,256.74,
EST PT VT LEVELIII,9000017,CDM,510,RC,99213,HCPCS,Outpatient,,,503.00,503.00,,295.51,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,295.51,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,243.5,48.41,,23.64,Percent of Total Billed Charges,48.41% of Total Billed Charges,74.12,100,,,fee Schedule,100% of BCBS fee schedule,74.12,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,236.41,47,,22.952,Percent of Total Billed Charges,47% of Total Billed Charges,74.12,100,,,Fee Schedule,100% of BCBS PPO fee schedule,295.51,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,236.41,47,,22.952,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,236.41,47,,22.952,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,68.52,115,,,Fee Schedule,115% of CMS OPPS Rate,68.52,115,,,Fee Schedule,115% of CMS OPPS Rate,68.52,295.51,
EST PT VT LEVELIV,9000018,CDM,510,RC,99214,HCPCS,Outpatient,,,664.10,664.10,,390.16,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,390.16,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,321.49,48.41,,2.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,108,100,,,fee Schedule,100% of BCBS fee schedule,108,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,312.13,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,108,100,,,Fee Schedule,100% of BCBS PPO fee schedule,390.16,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,312.13,47,,2.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,312.13,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,100.86,115,,,Fee Schedule,115% of CMS OPPS Rate,100.86,115,,,Fee Schedule,115% of CMS OPPS Rate,100.86,390.16,
EST PT VT LEVELV,9000019,CDM,510,RC,99215,HCPCS,Outpatient,,,731.00,731.00,,429.46,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,429.46,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,353.88,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,145.47,100,,,fee Schedule,100% of BCBS fee schedule,145.47,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,343.57,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,145.47,100,,,Fee Schedule,100% of BCBS PPO fee schedule,429.46,58.75,,2.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,343.57,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,343.57,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,149.14,115,,,Fee Schedule,115% of CMS OPPS Rate,149.14,115,,,Fee Schedule,115% of CMS OPPS Rate,145.47,429.46,
ACELLR XNGRF 100 CM2,9000020,CDM,360,RC,,,Outpatient,,,2229.85,2229.85,,1310.04,58.75,,5.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,1310.04,58.75,,5.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,1079.47,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,2006.87,90,,1605.496,Percent of Total Billed Charges,90% of Total Billed Charges,2006.87,90,,1605.496,Percent of Total Billed Charges,90% of Total Billed Charges,1048.03,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,2006.87,90,,1605.496,Percent of Total Billed Charges,90% of Total Billed Charges,1310.04,58.75,,5.264,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1048.03,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1048.03,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1048.03,47,,838.424,Percent of Total Billed Charges,47% of Total Billed Charges,1048.03,47,,838.424,Percent of Total Billed Charges,47% of Total Billed Charges,1048.03,2006.87,
NONHUM MET TISS/SQCM,9000021,CDM,636,RC,Q4102,HCPCS,Outpatient,,,10.68,10.68,,6.27,58.75,,14.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.27,58.75,,14.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.17,48.41,,2.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,9.61,90,,7.688,Percent of Total Billed Charges,90% of Total Billed Charges,9.61,90,,7.688,Percent of Total Billed Charges,90% of Total Billed Charges,5.02,47,,2.824,Percent of Total Billed Charges,47% of Total Billed Charges,9.61,90,,7.688,Percent of Total Billed Charges,90% of Total Billed Charges,6.27,58.75,,14.968,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.02,47,,2.824,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.02,47,,2.824,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.02,47,,4.016,Percent of Total Billed Charges,47% of Total Billed Charges,5.02,47,,4.016,Percent of Total Billed Charges,47% of Total Billed Charges,5.02,9.61,
DRAIN HEMATM/FLD PF,9000022,CDM,983,RC,10140,HCPCS,Outpatient,,,135.00,135.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
DRAN SKN ABSESSPF,9000023,CDM,983,RC,10061,HCPCS,Outpatient,,,188.50,188.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
DEBRIDE SKIN PART PF,9000024,CDM,983,RC,,,Outpatient,,,37.40,37.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
DEBRIDE SKIN FULL PF,9000025,CDM,983,RC,,,Outpatient,,,48.40,48.40,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
DEBRIDE SKN/TISS PF,9000026,CDM,983,RC,11042,HCPCS,Outpatient,,,64.35,64.35,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
DEBRIDE TISS/MUSC PF,9000027,CDM,983,RC,11043,HCPCS,Outpatient,,,268.00,268.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
DEBRD TISS/MUS/BN PF,9000028,CDM,983,RC,11044,HCPCS,Outpatient,,,371.00,371.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
BIOPSY SKIN LESN PF,9000029,CDM,983,RC,11100,HCPCS,Outpatient,,,56.00,56.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
WOUND SURG PREPPF,9000030,CDM,983,RC,15002,HCPCS,Outpatient,,,258.00,258.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
WOUND SURG PREPPF,9000031,CDM,983,RC,15004,HCPCS,Outpatient,,,320.00,320.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
APP SKNALGF AM/LG PF,9000032,CDM,983,RC,,,Outpatient,,,331.00,331.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
AP SKNALOGRT FNHFGPF,9000033,CDM,983,RC,,,Outpatient,,,379.00,379.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
APY TIS DER SB<100PF,9000034,CDM,983,RC,,,Outpatient,,,394.00,394.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
APL XNGRFT <100SQ PF,9000035,CDM,983,RC,,,Outpatient,,,394.00,394.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
APLY XNGRFT<100SQ PF,9000036,CDM,983,RC,,,Outpatient,,,414.50,414.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
AP ACLLAR XNGR<100PF,9000037,CDM,983,RC,,,Outpatient,,,589.00,589.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
CHEM CAUTERY TISS PF,9000038,CDM,983,RC,17250,HCPCS,Outpatient,,,41.00,41.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
APPLY PASTE BOOT PF,9000039,CDM,983,RC,29580,HCPCS,Outpatient,,,43.00,43.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
WC PF OFF/OP VTNEW1,9000040,CDM,983,RC,99201,HCPCS,Outpatient,,,28.50,28.50,25,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
WC PF OF/OP VT NEW 2,9000041,CDM,983,RC,99202,HCPCS,Outpatient,,,62.70,62.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
WC PF OFF/OP VTNEW3,9000042,CDM,983,RC,99203,HCPCS,Outpatient,,,87.00,87.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
WC PF OFF/OP VTNEW4,9000043,CDM,983,RC,99204,HCPCS,Outpatient,,,144.00,144.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
WC PF OFF/OP VTNEW5,9000044,CDM,983,RC,99205,HCPCS,Outpatient,,,189.00,189.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
WC PF OFF/OP VTEST1,9000045,CDM,983,RC,99211,HCPCS,Outpatient,,,11.00,11.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
WC PF OFF/OP VTEST2,9000046,CDM,983,RC,99212,HCPCS,Outpatient,,,29.00,29.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
WC PF OFF/OP VTEST3,9000047,CDM,983,RC,99213,HCPCS,Outpatient,,,56.00,56.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
WC PF OFF/OP VTEST4,9000048,CDM,983,RC,99214,HCPCS,Outpatient,,,88.00,88.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
WC PF OFF/OP VTEST5,9000049,CDM,983,RC,99215,HCPCS,Outpatient,,,125.50,125.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
MULTILAYER CMP APPLI,9000050,CDM,361,RC,29581,HCPCS,Outpatient,,,895.00,895.00,,525.81,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,525.81,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,433.27,48.41,,1931.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,146.72,100,,,fee Schedule,100% of ASC Tier Groupings ,146.72,100,,,Fee Schedule,100% of ASC Tier Groupings,420.65,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,146.72,100,,,Fee Schedule,100% of ASC Tier Groupings,525.81,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,55.7,100,,,Fee Schedule,100% of ASC Tier Groupings,420.65,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed charges,55.7,100,,,Fee Schedule,100% ASC Tier Groupings,420.65,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,28.27,115,,,Fee Schedule,115% of CMS OPPS Rate,28.27,115,,,Fee Schedule,115% of CMS OPPS Rate,28.27,525.81,
AC WN C SEL >OR=20SQ,9000052,CDM,361,RC,97598,HCPCS,Outpatient,,,895.00,895.00,,525.81,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,525.81,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,433.27,48.41,,1931.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,420.65,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,525.81,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,420.65,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,420.65,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,25,115,,,Fee Schedule,115% of CMS OPPS Rate,25,115,,,Fee Schedule,115% of CMS OPPS Rate,25,525.81,
ACT WND CARE NON SEL,9000053,CDM,361,RC,97602,HCPCS,Outpatient,,,895.00,895.00,,525.81,58.75,,483.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,525.81,58.75,,483.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,433.27,48.41,,577.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,167.75,100,,,fee Schedule,100% of BCBS fee schedule,167.75,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,420.65,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,167.75,100,,,Fee Schedule,100% of BCBS PPO fee schedule,525.81,58.75,,483.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,420.65,47,,560.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,420.65,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,420.65,47,,336.52,Percent of Total Billed Charges,47% of Total Billed Charges,420.65,47,,336.52,Percent of Total Billed Charges,47% of Total Billed Charges,167.75,525.81,
"NG PRE WD THY,OR=50S",9000054,CDM,361,RC,97605,HCPCS,Outpatient,,,895.00,895.00,,525.81,58.75,,1298.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,525.81,58.75,,1298.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,433.27,48.41,,577.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,167.75,100,,,fee Schedule,100% of BCBS fee schedule,167.75,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,420.65,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,167.75,100,,,Fee Schedule,100% of BCBS PPO fee schedule,525.81,58.75,,1298.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,420.65,47,,560.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,420.65,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,26.08,115,,,Fee Schedule,115% of CMS OPPS Rate,26.08,115,,,Fee Schedule,115% of CMS OPPS Rate,26.08,525.81,
NG PRE WD THY>OR=50S,9000055,CDM,361,RC,97606,HCPCS,Outpatient,,,895.00,895.00,,525.81,58.75,,3.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,525.81,58.75,,3.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,433.27,48.41,,577.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,306.74,100,,,fee Schedule,100% of BCBS fee schedule,306.74,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,420.65,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,306.74,100,,,Fee Schedule,100% of BCBS PPO fee schedule,525.81,58.75,,3.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,420.65,47,,560.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,420.65,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.27,115,,,Fee Schedule,115% of CMS OPPS Rate,28.27,115,,,Fee Schedule,115% of CMS OPPS Rate,28.27,525.81,
MULTILAYER CMP AP PF,9000056,CDM,983,RC,29581,HCPCS,Outpatient,,,277.50,277.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
AWC SEL<OR=20 SQC PF,9000057,CDM,983,RC,97597,HCPCS,Outpatient,,,102.90,102.90,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
AWC SEL>OR=20 SQC PF,9000058,CDM,983,RC,97598,HCPCS,Outpatient,,,139.70,139.70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
"NG PS WD THY,OR=50PF",9000059,CDM,983,RC,97605,HCPCS,Outpatient,,,174.50,174.50,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
NG PR WD TH>=50SQ PF,9000060,CDM,983,RC,97606,HCPCS,Outpatient,,,100.00,100.00,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
ABD 5X9,9000061,CDM,272,RC,A6252,HCPCS,Outpatient,,,17.05,17.05,,10.02,58.75,,3.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.02,58.75,,3.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.25,48.41,,474.224,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8.01,47,,460.416,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,10.02,58.75,,3.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.44,100,,,Fee Schedule,100% of AR Medicaid Rate,8.01,47,,460.416,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.01,47,,460.416,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.01,47,,6.408,Percent of Total Billed Charges,47% of Total Billed Charges,8.01,47,,6.408,Percent of Total Billed Charges,47% of Total Billed Charges,4.44,10.02,
ABD 8X10,9000062,CDM,272,RC,A6253,HCPCS,Outpatient,,,33.30,33.30,,19.56,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.56,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.12,48.41,,149.104,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15.65,47,,144.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.56,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.64,100,,,Fee Schedule,100% of AR Medicaid Rate,15.65,47,,144.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.65,47,,144.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.65,47,,12.52,Percent of Total Billed Charges,47% of Total Billed Charges,15.65,47,,12.52,Percent of Total Billed Charges,47% of Total Billed Charges,8.64,19.56,
ACTICOAT 3 4X4,9000063,CDM,272,RC,A6197,HCPCS,Outpatient,,,86.30,86.30,,50.7,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.7,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.78,48.41,,106.24,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,40.56,47,,103.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.7,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.44,100,,,Fee Schedule,100% of AR Medicaid Rate,40.56,47,,103.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.56,47,,103.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.56,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,40.56,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,22.44,50.7,
ADAPTIC 3X3,9000064,CDM,272,RC,A6222,HCPCS,Outpatient,,,11.20,11.20,,6.58,58.75,,3.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.58,58.75,,3.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.42,48.41,,766.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.26,47,,744.48,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.58,58.75,,3.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.91,100,,,Fee Schedule,100% of AR Medicaid Rate,5.26,47,,744.48,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.26,47,,744.48,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.26,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,5.26,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,2.91,6.58,
ADAPTIC 3X8,9000065,CDM,272,RC,A6223,HCPCS,Outpatient,,,12.70,12.70,,7.46,58.75,,5.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.46,58.75,,5.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.15,48.41,,140.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.97,47,,136.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.46,58.75,,5.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.31,100,,,Fee Schedule,100% of AR Medicaid Rate,5.97,47,,136.488,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.97,47,,136.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.97,47,,4.776,Percent of Total Billed Charges,47% of Total Billed Charges,5.97,47,,4.776,Percent of Total Billed Charges,47% of Total Billed Charges,3.31,7.46,
ALLEVYN THIN 4X4,9000066,CDM,272,RC,A6209,HCPCS,Outpatient,,,39.25,39.25,,23.06,58.75,,17.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.06,58.75,,17.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,19,48.41,,867.896,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18.45,47,,842.616,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.06,58.75,,17.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.2,100,,,Fee Schedule,100% of AR Medicaid Rate,18.45,47,,842.616,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.45,47,,842.616,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.45,47,,14.76,Percent of Total Billed Charges,47% of Total Billed Charges,18.45,47,,14.76,Percent of Total Billed Charges,47% of Total Billed Charges,10.2,23.06,
AQUACEL AG 2X2,9000067,CDM,272,RC,A6196,HCPCS,Outpatient,,,38.60,38.60,,22.68,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.68,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.69,48.41,,230.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18.14,47,,223.344,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.68,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.04,100,,,Fee Schedule,100% of AR Medicaid Rate,18.14,47,,223.344,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.14,47,,223.344,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.14,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,18.14,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,10.04,22.68,
AQUACEL AG 4X4.7,9000068,CDM,272,RC,A6197,HCPCS,Outpatient,,,86.30,86.30,,50.7,58.75,,688.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.7,58.75,,688.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.78,48.41,,33.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,40.56,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.7,58.75,,688.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.44,100,,,Fee Schedule,100% of AR Medicaid Rate,40.56,47,,32.448,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.56,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.56,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,40.56,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,22.44,50.7,
AQUACEL AG ROPE3UNI,9000069,CDM,272,RC,A6199,HCPCS,Outpatient,,,27.75,27.75,,16.3,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.3,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.43,48.41,,10.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.04,47,,10.432,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,16.3,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.2,100,,,Fee Schedule,100% of AR Medicaid Rate,13.04,47,,10.432,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.04,47,,10.432,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.04,47,,10.432,Percent of Total Billed Charges,47% of Total Billed Charges,13.04,47,,10.432,Percent of Total Billed Charges,47% of Total Billed Charges,7.2,16.3,
CALCIUM ALGINATE 2X2,9000070,CDM,272,RC,A6196,HCPCS,Outpatient,,,38.60,38.60,,22.68,58.75,,334.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.68,58.75,,334.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.69,48.41,,14.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18.14,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.68,58.75,,334.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.04,100,,,Fee Schedule,100% of AR Medicaid Rate,18.14,47,,14.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.14,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.14,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,18.14,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,10.04,22.68,
CALCIUM ALGINATE 4X4,9000071,CDM,272,RC,A6196,HCPCS,Outpatient,,,38.60,38.60,,22.68,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.68,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.69,48.41,,14.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18.14,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.68,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.04,100,,,Fee Schedule,100% of AR Medicaid Rate,18.14,47,,14.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.14,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.14,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,18.14,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,10.04,22.68,
COBAN 4,9000072,CDM,272,RC,A6454,HCPCS,Outpatient,,,4.05,4.05,,2.38,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.38,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.96,48.41,,1.568,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.9,47,,1.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.38,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.07,100,,,Fee Schedule,100% of AR Medicaid Rate,1.9,47,,1.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1.9,47,,1.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1.9,47,,1.52,Percent of Total Billed Charges,47% of Total Billed Charges,1.9,47,,1.52,Percent of Total Billed Charges,47% of Total Billed Charges,1.07,2.38,
FIBRACOL 2X2,9000073,CDM,272,RC,A6021,HCPCS,Outpatient,,,110.35,110.35,,64.83,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.83,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,53.42,48.41,,42.736,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.83,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.69,100,,,Fee Schedule,100% of AR Medicaid Rate,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,28.69,64.83,
FIBRACOL 4X4 3/8,9000074,CDM,272,RC,A6022,HCPCS,Outpatient,,,110.35,110.35,,64.83,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.83,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,53.42,48.41,,42.736,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.83,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.69,100,,,Fee Schedule,100% of AR Medicaid Rate,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,28.69,64.83,
GZ BRDR DRESSING 4X4,9000075,CDM,272,RC,A6219,HCPCS,Outpatient,,,5.00,5.00,,2.94,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.94,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.42,48.41,,1.936,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2.94,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.3,100,,,Fee Schedule,100% of AR Medicaid Rate,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,2.35,47,,1.88,Percent of Total Billed Charges,47% of Total Billed Charges,1.3,2.94,
GZ BRDR DRESSING 6X6,9000076,CDM,272,RC,A6220,HCPCS,Outpatient,,,13.55,13.55,,7.96,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.96,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.56,48.41,,5.248,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.37,47,,5.096,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,7.96,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.54,100,,,Fee Schedule,100% of AR Medicaid Rate,6.37,47,,5.096,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,6.37,47,,5.096,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,6.37,47,,5.096,Percent of Total Billed Charges,47% of Total Billed Charges,6.37,47,,5.096,Percent of Total Billed Charges,47% of Total Billed Charges,3.54,7.96,
GAUZE CONGORM 3IN,9000077,CDM,272,RC,A6449,HCPCS,Outpatient,,,9.20,9.20,,5.41,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.41,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.45,48.41,,3.56,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.32,47,,3.456,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.41,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.39,100,,,Fee Schedule,100% of AR Medicaid Rate,4.32,47,,3.456,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.32,47,,3.456,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.32,47,,3.456,Percent of Total Billed Charges,47% of Total Billed Charges,4.32,47,,3.456,Percent of Total Billed Charges,47% of Total Billed Charges,2.39,5.41,
HYDROFERA BLUE 4X4,9000078,CDM,272,RC,A6209,HCPCS,Outpatient,,,39.25,39.25,,23.06,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,23.06,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,19,48.41,,15.2,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18.45,47,,14.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,23.06,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.2,100,,,Fee Schedule,100% of AR Medicaid Rate,18.45,47,,14.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.45,47,,14.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.45,47,,14.76,Percent of Total Billed Charges,47% of Total Billed Charges,18.45,47,,14.76,Percent of Total Billed Charges,47% of Total Billed Charges,10.2,23.06,
HYDROGEL 4 0Z TUBE,9000079,CDM,272,RC,A6248,HCPCS,Outpatient,,,85.25,85.25,,50.08,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.08,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.27,48.41,,33.016,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,40.07,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.08,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.17,100,,,Fee Schedule,100% of AR Medicaid Rate,40.07,47,,32.056,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.07,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.07,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,40.07,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,22.17,50.08,
HYPERGEL 5GM TH/OZ,9000080,CDM,272,RC,A6248,HCPCS,Outpatient,,,85.25,85.25,,50.08,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.08,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.27,48.41,,33.016,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,40.07,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.08,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.17,100,,,Fee Schedule,100% of AR Medicaid Rate,40.07,47,,32.056,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.07,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.07,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,40.07,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,22.17,50.08,
IODOFLEX 5GM/THOZ,9000081,CDM,272,RC,A6261,HCPCS,Outpatient,,,33.20,33.20,,19.51,58.75,,688.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.51,58.75,,688.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.07,48.41,,12.856,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15.6,47,,12.48,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.51,58.75,,688.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.6,47,,12.48,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.6,47,,12.48,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.6,47,,12.48,Percent of Total Billed Charges,47% of Total Billed Charges,15.6,47,,12.48,Percent of Total Billed Charges,47% of Total Billed Charges,15.6,19.51,
IODOSORB GEL40 TH/OZ,9000082,CDM,272,RC,A6261,HCPCS,Outpatient,,,234.25,234.25,,137.62,58.75,,1900.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,137.62,58.75,,1900.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,113.4,48.41,,90.72,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,110.1,47,,88.08,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,137.62,58.75,,1900.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,110.1,47,,88.08,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,110.1,47,,88.08,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,110.1,47,,88.08,Percent of Total Billed Charges,47% of Total Billed Charges,110.1,47,,88.08,Percent of Total Billed Charges,47% of Total Billed Charges,110.1,137.62,
MEPILEX BORDER 4X4,9000083,CDM,272,RC,A6212,HCPCS,Outpatient,,,50.95,50.95,,29.93,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.93,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.66,48.41,,19.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23.95,47,,19.16,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.93,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.25,100,,,Fee Schedule,100% of AR Medicaid Rate,23.95,47,,19.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.95,47,,19.16,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.95,47,,19.16,Percent of Total Billed Charges,47% of Total Billed Charges,23.95,47,,19.16,Percent of Total Billed Charges,47% of Total Billed Charges,13.25,29.93,
MEPILEX BORDER 6X6,9000084,CDM,272,RC,A6213,HCPCS,Outpatient,,,50.95,50.95,,29.93,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.93,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,24.66,48.41,,19.728,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23.95,47,,19.16,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,29.93,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.95,47,,19.16,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,23.95,47,,19.16,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,23.95,47,,19.16,Percent of Total Billed Charges,47% of Total Billed Charges,23.95,47,,19.16,Percent of Total Billed Charges,47% of Total Billed Charges,23.95,29.93,
MEPITEL 2X3,9000085,CDM,272,RC,A6206,HCPCS,Outpatient,,,24.50,24.50,,14.39,58.75,,4197.976,Percent of Total Billed Charges,58.75% of Total Billed Charges,14.39,58.75,,4197.976,Percent of Total Billed Charges,58.75% of Total Billed Charges,11.86,48.41,,9.488,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11.52,47,,9.216,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,14.39,58.75,,4197.976,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.52,47,,9.216,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,11.52,47,,9.216,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,11.52,47,,9.216,Percent of Total Billed Charges,47% of Total Billed Charges,11.52,47,,9.216,Percent of Total Billed Charges,47% of Total Billed Charges,11.52,14.39,
MEPITEL 3X4,9000086,CDM,272,RC,A6206,HCPCS,Outpatient,,,33.45,33.45,,19.65,58.75,,4197.976,Percent of Total Billed Charges,58.75% of Total Billed Charges,19.65,58.75,,4197.976,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.19,48.41,,12.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15.72,47,,12.576,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,19.65,58.75,,4197.976,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.72,47,,12.576,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,15.72,47,,12.576,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,15.72,47,,12.576,Percent of Total Billed Charges,47% of Total Billed Charges,15.72,47,,12.576,Percent of Total Billed Charges,47% of Total Billed Charges,15.72,19.65,
MESALT 4X4,9000087,CDM,272,RC,A6222,HCPCS,Outpatient,,,11.20,11.20,,6.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.42,48.41,,4.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.26,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.91,100,,,Fee Schedule,100% of AR Medicaid Rate,5.26,47,,4.208,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.26,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.26,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,5.26,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,2.91,6.58,
NUGAUZE 1/2 PLAIN,9000088,CDM,272,RC,A6407,HCPCS,Outpatient,,,9.85,9.85,,5.79,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.79,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.77,48.41,,3.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.79,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.55,100,,,Fee Schedule,100% of AR Medicaid Rate,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,2.55,5.79,
NUGAUZE 1/4 PLAIN,9000089,CDM,272,RC,A6407,HCPCS,Outpatient,,,9.85,9.85,,5.79,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.79,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.77,48.41,,3.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.79,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.55,100,,,Fee Schedule,100% of AR Medicaid Rate,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,2.55,5.79,
PRISMA 4.34 SQ IN,9000090,CDM,272,RC,A6021,HCPCS,Outpatient,,,110.35,110.35,,64.83,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.83,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,53.42,48.41,,42.736,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.83,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.69,100,,,Fee Schedule,100% of AR Medicaid Rate,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,28.69,64.83,
PROMOGRAN 4.34 SQ IN,9000091,CDM,272,RC,A6021,HCPCS,Outpatient,,,110.35,110.35,,64.83,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.83,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,53.42,48.41,,42.736,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,64.83,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,28.69,100,,,Fee Schedule,100% of AR Medicaid Rate,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,51.86,47,,41.488,Percent of Total Billed Charges,47% of Total Billed Charges,28.69,64.83,
SILVERCEL 2X2,9000092,CDM,272,RC,A6196,HCPCS,Outpatient,,,38.60,38.60,,22.68,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.68,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.69,48.41,,14.952,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18.14,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,22.68,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.04,100,,,Fee Schedule,100% of AR Medicaid Rate,18.14,47,,14.512,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,18.14,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,18.14,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,18.14,47,,14.512,Percent of Total Billed Charges,47% of Total Billed Charges,10.04,22.68,
SILVERCEL41/4X41X4,9000093,CDM,272,RC,A6197,HCPCS,Outpatient,,,86.30,86.30,,50.7,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.7,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.78,48.41,,33.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,40.56,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.7,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.44,100,,,Fee Schedule,100% of AR Medicaid Rate,40.56,47,,32.448,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.56,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.56,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,40.56,47,,32.448,Percent of Total Billed Charges,47% of Total Billed Charges,22.44,50.7,
SILV-A-GEL 3 OZ,9000094,CDM,272,RC,A6248,HCPCS,Outpatient,,,85.25,85.25,,50.08,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.08,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,41.27,48.41,,33.016,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,40.07,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,50.08,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,22.17,100,,,Fee Schedule,100% of AR Medicaid Rate,40.07,47,,32.056,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,40.07,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,40.07,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,40.07,47,,32.056,Percent of Total Billed Charges,47% of Total Billed Charges,22.17,50.08,
STOCKINETTE 2PER YD,9000095,CDM,272,RC,A6457,HCPCS,Outpatient,,,6.00,6.00,,3.53,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.53,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.55,100,,,Fee Schedule,100% of AR Medicaid Rate,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,1.55,3.53,
STOCKINETTE 3PER YD,9000096,CDM,272,RC,A6457,HCPCS,Outpatient,,,6.00,6.00,,3.53,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.53,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.55,100,,,Fee Schedule,100% of AR Medicaid Rate,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,1.55,3.53,
STOCKINETTE 4PER YD,9000097,CDM,272,RC,A6457,HCPCS,Outpatient,,,6.00,6.00,,3.53,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.53,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.9,48.41,,2.32,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,3.53,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.55,100,,,Fee Schedule,100% of AR Medicaid Rate,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,2.82,47,,2.256,Percent of Total Billed Charges,47% of Total Billed Charges,1.55,3.53,
VASELINE GAUZE 3X9,9000098,CDM,272,RC,A6222,HCPCS,Outpatient,,,11.20,11.20,,6.58,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,6.58,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.42,48.41,,4.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.26,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,6.58,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.91,100,,,Fee Schedule,100% of AR Medicaid Rate,5.26,47,,4.208,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.26,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.26,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,5.26,47,,4.208,Percent of Total Billed Charges,47% of Total Billed Charges,2.91,6.58,
VIGILON 4X4,9000099,CDM,272,RC,A6242,HCPCS,Outpatient,,,31.85,31.85,,18.71,58.75,,184.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.71,58.75,,184.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.42,48.41,,12.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14.97,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.71,58.75,,184.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.26,100,,,Fee Schedule,100% of AR Medicaid Rate,14.97,47,,11.976,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.97,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.97,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,14.97,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,8.26,18.71,
XCELL 3.5 X 3/5,9000100,CDM,272,RC,A6242,HCPCS,Outpatient,,,31.85,31.85,,18.71,58.75,,320.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.71,58.75,,320.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.42,48.41,,12.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14.97,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.71,58.75,,320.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.26,100,,,Fee Schedule,100% of AR Medicaid Rate,14.97,47,,11.976,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.97,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.97,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,14.97,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,8.26,18.71,
XCELL AM 3.5 X 3.5,9000101,CDM,272,RC,A6242,HCPCS,Outpatient,,,31.85,31.85,,18.71,58.75,,655.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,18.71,58.75,,655.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,15.42,48.41,,12.336,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14.97,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,18.71,58.75,,655.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.26,100,,,Fee Schedule,100% of AR Medicaid Rate,14.97,47,,11.976,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,14.97,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,14.97,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,14.97,47,,11.976,Percent of Total Billed Charges,47% of Total Billed Charges,8.26,18.71,
XCELL AM ROPE,9000102,CDM,272,RC,A6407,HCPCS,Outpatient,,,9.85,9.85,,5.79,58.75,,45.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.79,58.75,,45.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.77,48.41,,3.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.79,58.75,,45.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.55,100,,,Fee Schedule,100% of AR Medicaid Rate,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,2.55,5.79,
XCELL ROPE,9000103,CDM,272,RC,A6407,HCPCS,Outpatient,,,9.85,9.85,,5.79,58.75,,575.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.79,58.75,,575.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.77,48.41,,3.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5.79,58.75,,575.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,2.55,100,,,Fee Schedule,100% of AR Medicaid Rate,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,4.63,47,,3.704,Percent of Total Billed Charges,47% of Total Billed Charges,2.55,5.79,
FOAM 4X8,9000104,CDM,272,RC,A6210,HCPCS,Outpatient,,,104.60,104.60,,61.45,58.75,,180.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,61.45,58.75,,180.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,50.64,48.41,,40.512,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,49.16,47,,39.328,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,61.45,58.75,,180.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,27.19,100,,,Fee Schedule,100% of AR Medicaid Rate,49.16,47,,39.328,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,49.16,47,,39.328,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,49.16,47,,39.328,Percent of Total Billed Charges,47% of Total Billed Charges,49.16,47,,39.328,Percent of Total Billed Charges,47% of Total Billed Charges,27.19,61.45,
DEBRIDE SUB TISEA A,9000105,CDM,360,RC,11045,HCPCS,Outpatient,,,1095.00,1095.00,,643.31,58.75,,128.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,643.31,58.75,,128.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,530.09,48.41,,424.072,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,514.65,47,,411.72,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,643.31,58.75,,128.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,514.65,47,,411.72,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,514.65,47,,411.72,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,25.38,115,,,Fee Schedule,115% of CMS OPPS Rate,25.38,115,,,Fee Schedule,115% of CMS OPPS Rate,25.38,643.31,
DEBR MUSFAS EA ADDL,9000106,CDM,361,RC,11046,HCPCS,Outpatient,,,995.00,995.00,,584.56,58.75,,930.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,584.56,58.75,,930.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,481.68,48.41,,385.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,467.65,47,,374.12,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,584.56,58.75,,930.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,467.65,47,,374.12,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,467.65,47,,374.12,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,54.89,115,,,Fee Schedule,115% of CMS OPPS Rate,54.89,115,,,Fee Schedule,115% of CMS OPPS Rate,54.89,584.56,
DEBRIDE BONE EAADDL,9000107,CDM,361,RC,11047,HCPCS,Outpatient,,,2671.00,2671.00,,1569.21,58.75,,170.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,1569.21,58.75,,170.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,1293.03,48.41,,1034.424,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1255.37,47,,1004.296,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,1569.21,58.75,,170.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1255.37,47,,1004.296,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1255.37,47,,1004.296,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,97.37,115,,,Fee Schedule,115% of CMS OPPS Rate,97.37,115,,,Fee Schedule,115% of CMS OPPS Rate,97.37,1569.21,
DEB DEVIT TISS DEREP,9000108,CDM,361,RC,97597,HCPCS,Outpatient,,,995.00,995.00,,584.56,58.75,,1053.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,584.56,58.75,,1053.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,481.68,48.41,,385.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,167.75,100,,,fee Schedule,100% of BCBS fee schedule,167.75,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,467.65,47,,374.12,Percent of Total Billed Charges,47% of Total Billed Charges,167.75,100,,,Fee Schedule,100% of BCBS PPO fee schedule,584.56,58.75,,1053.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,467.65,47,,374.12,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,467.65,47,,374.12,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,36.96,115,,,Fee Schedule,115% of CMS OPPS Rate,36.96,115,,,Fee Schedule,115% of CMS OPPS Rate,36.96,584.56,
DEBR SELECTIVE EA AD,9000109,CDM,361,RC,97598,HCPCS,Outpatient,,,995.00,995.00,,584.56,58.75,,279.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,584.56,58.75,,279.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,481.68,48.41,,385.344,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,467.65,47,,374.12,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,584.56,58.75,,279.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,467.65,47,,374.12,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,467.65,47,,374.12,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,25,115,,,Fee Schedule,115% of CMS OPPS Rate,25,115,,,Fee Schedule,115% of CMS OPPS Rate,25,584.56,
PAIR/CUT ONE LESION,9000110,CDM,983,RC,11055,HCPCS,Outpatient,,,1132.20,1132.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
OASIS WD MATX PER UN,9000111,CDM,361,RC,Q4102,HCPCS,Outpatient,,,18.00,18.00,,10.58,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.58,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.71,48.41,,6.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,8.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,16.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,10.58,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,16.2,
OASIS WD MATX DISCAR,9000112,CDM,361,RC,Q4102,HCPCS,Outpatient,,,18.00,18.00,,10.58,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,10.58,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,8.71,48.41,,6.968,Percent of Total Billed Charges,48.41% of Total Billed Charges,16.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,16.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,8.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,16.2,90,,12.96,Percent of Total Billed Charges,90% of Total Billed Charges,10.58,58.75,,8.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,8.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,8.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,47,,6.768,Percent of Total Billed Charges,47% of Total Billed Charges,8.46,16.2,
DERMAGRAFT 1 SQ.CM,9000114,CDM,636,RC,Q4106,HCPCS,Outpatient,,,110.02,110.02,,64.64,58.75,,51.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,64.64,58.75,,51.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,53.26,48.41,,42.608,Percent of Total Billed Charges,48.41% of Total Billed Charges,99.02,90,,79.216,Percent of Total Billed Charges,90% of Total Billed Charges,99.02,90,,79.216,Percent of Total Billed Charges,90% of Total Billed Charges,51.71,47,,41.368,Percent of Total Billed Charges,47% of Total Billed Charges,99.02,90,,79.216,Percent of Total Billed Charges,90% of Total Billed Charges,64.64,58.75,,51.712,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,51.71,47,,41.368,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,51.71,47,,41.368,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,51.71,47,,41.368,Percent of Total Billed Charges,47% of Total Billed Charges,51.71,47,,41.368,Percent of Total Billed Charges,47% of Total Billed Charges,51.71,99.02,
DERMAGRAFT TOT DISCD,9000115,CDM,361,RC,Q4106,HCPCS,Outpatient,,,117.00,117.00,,68.74,58.75,,54.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,68.74,58.75,,54.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,56.64,48.41,,45.312,Percent of Total Billed Charges,48.41% of Total Billed Charges,105.3,90,,84.24,Percent of Total Billed Charges,90% of Total Billed Charges,105.3,90,,84.24,Percent of Total Billed Charges,90% of Total Billed Charges,54.99,47,,43.992,Percent of Total Billed Charges,47% of Total Billed Charges,105.3,90,,84.24,Percent of Total Billed Charges,90% of Total Billed Charges,68.74,58.75,,54.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,54.99,47,,43.992,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,54.99,47,,43.992,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,54.99,47,,43.992,Percent of Total Billed Charges,47% of Total Billed Charges,54.99,47,,43.992,Percent of Total Billed Charges,47% of Total Billed Charges,54.99,105.3,
DRES/DEBR BURN LARGE,9000116,CDM,361,RC,16030,HCPCS,Outpatient,,,1132.20,1132.20,,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,548.1,48.41,,438.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,,Fee Schedule,100% of ASC Tier Groupings,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,,Fee Schedule,100% of ASC Tier Groupings,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,132.81,115,,,Fee Schedule,115% of CMS OPPS Rate,132.81,115,,,Fee Schedule,115% of CMS OPPS Rate,132.81,665.17,
PAIR/CUT 2-4 LESIONS,9000117,CDM,983,RC,11056,HCPCS,Outpatient,,,1132.20,1132.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
PAIR/CUT OVER 4LESN,9000118,CDM,983,RC,11057,HCPCS,Outpatient,,,1132.20,1132.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
INT TRMT 1ST DEG BUR,9000119,CDM,983,RC,16000,HCPCS,Outpatient,,,1132.20,1132.20,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,
DRES/DEBR BURN SMALL,9000120,CDM,361,RC,16020,HCPCS,Outpatient,,,1132.20,1132.20,,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,548.1,48.41,,438.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,56.1,115,,,Fee Schedule,115% of CMS OPPS Rate,56.1,115,,,Fee Schedule,115% of CMS OPPS Rate,56.1,665.17,
DRES/DEBR BURN MED,9000121,CDM,361,RC,16025,HCPCS,Outpatient,,,1132.20,1132.20,,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,548.1,48.41,,438.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.6,100,,,Fee Schedule,100% of ASC Tier Groupings,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed charges,75.6,100,,,Fee Schedule,100% ASC Tier Groupings,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,112.22,115,,,Fee Schedule,115% of CMS OPPS Rate,112.22,115,,,Fee Schedule,115% of CMS OPPS Rate,75.6,665.17,
AP SKNSUB GR LG25CM,9000122,CDM,361,RC,15271,HCPCS,Outpatient,,,4988.32,4988.32,,2930.64,58.75,,2344.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,2930.64,58.75,,2344.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,2414.85,48.41,,1931.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,1774.08,100,,,fee Schedule,100% of ASC Tier Groupings ,1774.08,100,,,Fee Schedule,100% of ASC Tier Groupings,2344.51,47,,1875.608,Percent of Total Billed Charges,47% of Total Billed Charges,1774.08,100,,,Fee Schedule,100% of ASC Tier Groupings,2930.64,58.75,,2344.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.01,100,,,Fee Schedule,100% of ASC Tier Groupings,2344.51,47,,1875.608,Percent of Total Billed Charges,47% of Total Billed charges,721.01,100,,,Fee Schedule,100% ASC Tier Groupings,2344.51,47,,1875.608,Percent of Total Billed Charges,47% of Total Billed Charges,620,100,,,Fee Schedule,100% of ASC Tier Groupings,85.76,115,,,Fee Schedule,115% of CMS OPPS Rate,85.76,115,,,Fee Schedule,115% of CMS OPPS Rate,85.76,2930.64,
AP SKN SUB EA ADD 25,9000123,CDM,361,RC,15272,HCPCS,Outpatient,,,4988.32,4988.32,,2930.64,58.75,,2344.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,2930.64,58.75,,2344.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,2414.85,48.41,,1931.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2344.51,47,,1875.608,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2930.64,58.75,,2344.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2344.51,47,,1875.608,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2344.51,47,,1875.608,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,17.2,115,,,Fee Schedule,115% of CMS OPPS Rate,17.2,115,,,Fee Schedule,115% of CMS OPPS Rate,17.2,2930.64,
AP SKNSUB GR LG100C,9000124,CDM,361,RC,15273,HCPCS,Outpatient,,,8932.87,8932.87,,5248.06,58.75,,4198.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,5248.06,58.75,,4198.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,4324.4,48.41,,3459.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,3253.6,100,,,fee Schedule,100% of ASC Tier Groupings ,3253.6,100,,,Fee Schedule,100% of ASC Tier Groupings,4198.45,47,,3358.76,Percent of Total Billed Charges,47% of Total Billed Charges,3253.6,100,,,Fee Schedule,100% of ASC Tier Groupings,5248.06,58.75,,4198.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,1482.27,100,,,Fee Schedule,100% of ASC Tier Groupings,4198.45,47,,3358.76,Percent of Total Billed Charges,47% of Total Billed charges,1482.27,100,,,Fee Schedule,100% ASC Tier Groupings,4198.45,47,,3358.76,Percent of Total Billed Charges,47% of Total Billed Charges,1302,100,,,Fee Schedule,100% of ASC Tier Groupings,195.43,115,,,Fee Schedule,115% of CMS OPPS Rate,195.43,115,,,Fee Schedule,115% of CMS OPPS Rate,195.43,5248.06,
AP SKNSUB EA ADD 100,9000125,CDM,361,RC,15274,HCPCS,Outpatient,,,8932.87,8932.87,,5248.06,58.75,,4198.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,5248.06,58.75,,4198.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,4324.4,48.41,,3459.52,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4198.45,47,,3358.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5248.06,58.75,,4198.448,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4198.45,47,,3358.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4198.45,47,,3358.76,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,44.03,115,,,Fee Schedule,115% of CMS OPPS Rate,44.03,115,,,Fee Schedule,115% of CMS OPPS Rate,44.03,5248.06,
AP SKNSUB FT 1ST 25C,9000126,CDM,361,RC,15275,HCPCS,Outpatient,,,4988.32,4988.32,,2930.64,58.75,,2344.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,2930.64,58.75,,2344.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,2414.85,48.41,,1931.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,1774.08,100,,,fee Schedule,100% of ASC Tier Groupings ,1774.08,100,,,Fee Schedule,100% of ASC Tier Groupings,2344.51,47,,1875.608,Percent of Total Billed Charges,47% of Total Billed Charges,1774.08,100,,,Fee Schedule,100% of ASC Tier Groupings,2930.64,58.75,,2344.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.01,100,,,Fee Schedule,100% of ASC Tier Groupings,2344.51,47,,1875.608,Percent of Total Billed Charges,47% of Total Billed charges,721.01,100,,,Fee Schedule,100% ASC Tier Groupings,2344.51,47,,1875.608,Percent of Total Billed Charges,47% of Total Billed Charges,620,100,,,Fee Schedule,100% of ASC Tier Groupings,96.81,115,,,Fee Schedule,115% of CMS OPPS Rate,96.81,115,,,Fee Schedule,115% of CMS OPPS Rate,96.81,2930.64,
AP SKNSUB FT EAAD 25,9000127,CDM,361,RC,15276,HCPCS,Outpatient,,,4988.32,4988.32,,2930.64,58.75,,2344.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,2930.64,58.75,,2344.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,2414.85,48.41,,1931.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2344.51,47,,1875.608,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2930.64,58.75,,2344.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2344.51,47,,1875.608,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2344.51,47,,1875.608,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,25.51,115,,,Fee Schedule,115% of CMS OPPS Rate,25.51,115,,,Fee Schedule,115% of CMS OPPS Rate,25.51,2930.64,
AP SKNSUB GR FT1ST,9000128,CDM,361,RC,15277,HCPCS,Outpatient,,,4988.22,4988.22,,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2414.8,48.41,,1931.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,1774.08,100,,,fee Schedule,100% of ASC Tier Groupings ,1774.08,100,,,Fee Schedule,100% of ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,1774.08,100,,,Fee Schedule,100% of ASC Tier Groupings,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.01,100,,,Fee Schedule,100% of ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed charges,721.01,100,,,Fee Schedule,100% ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,620,100,,,Fee Schedule,100% of ASC Tier Groupings,225.17,115,,,Fee Schedule,115% of CMS OPPS Rate,225.17,115,,,Fee Schedule,115% of CMS OPPS Rate,225.17,2930.58,
AP SKSB FT EA AD 100,9000129,CDM,361,RC,15278,HCPCS,Outpatient,,,4988.22,4988.22,,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2414.8,48.41,,1931.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,55.96,115,,,Fee Schedule,115% of CMS OPPS Rate,55.96,115,,,Fee Schedule,115% of CMS OPPS Rate,55.96,2930.58,
PAIR/CUT SNGL LESION,9000130,CDM,361,RC,11055,HCPCS,Outpatient,,,1132.20,1132.20,,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,548.1,48.41,,438.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,16.15,115,,,Fee Schedule,115% of CMS OPPS Rate,16.15,115,,,Fee Schedule,115% of CMS OPPS Rate,16.15,665.17,
PAIR/CUT 2-4 LESIONS,9000131,CDM,361,RC,11056,HCPCS,Outpatient,,,1132.20,1132.20,,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,548.1,48.41,,438.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,23.21,115,,,Fee Schedule,115% of CMS OPPS Rate,23.21,115,,,Fee Schedule,115% of CMS OPPS Rate,23.21,665.17,
PAIR/CUT OVER 4LESN,9000132,CDM,361,RC,11057,HCPCS,Outpatient,,,1132.20,1132.20,,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,548.1,48.41,,438.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,54.88,100,,,Fee Schedule,100% of ASC Tier Groupings,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed charges,54.88,100,,,Fee Schedule,100% ASC Tier Groupings,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,29.74,115,,,Fee Schedule,115% of CMS OPPS Rate,29.74,115,,,Fee Schedule,115% of CMS OPPS Rate,29.74,665.17,
INTL TRT 1ST DGBURN,9000133,CDM,361,RC,16000,HCPCS,Outpatient,,,1132.20,1132.20,,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,548.1,48.41,,438.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,46.55,115,,,Fee Schedule,115% of CMS OPPS Rate,46.55,115,,,Fee Schedule,115% of CMS OPPS Rate,46.55,665.17,
DRES/DEBRD BURNSMAL,9000134,CDM,361,RC,16020,HCPCS,Outpatient,,,1132.20,1132.20,,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,548.1,48.41,,438.48,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,665.17,58.75,,532.136,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,532.13,47,,425.704,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,56.1,115,,,Fee Schedule,115% of CMS OPPS Rate,56.1,115,,,Fee Schedule,115% of CMS OPPS Rate,56.1,665.17,
DRES/DBRD BURN MEDIM,9000135,CDM,361,RC,16025,HCPCS,Outpatient,,,1029.25,1029.25,,604.68,58.75,,483.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,604.68,58.75,,483.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,498.26,48.41,,398.608,Percent of Total Billed Charges,48.41% of Total Billed Charges,191.52,100,,,fee Schedule,100% of ASC Tier Groupings ,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,483.75,47,,387,Percent of Total Billed Charges,47% of Total Billed Charges,191.52,100,,,Fee Schedule,100% of ASC Tier Groupings,604.68,58.75,,483.744,Percent of Total Billed Charges,58.75% of Total Billed Charges,75.6,100,,,Fee Schedule,100% of ASC Tier Groupings,483.75,47,,387,Percent of Total Billed Charges,47% of Total Billed charges,75.6,100,,,Fee Schedule,100% ASC Tier Groupings,483.75,47,,387,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,112.22,115,,,Fee Schedule,115% of CMS OPPS Rate,112.22,115,,,Fee Schedule,115% of CMS OPPS Rate,75.6,604.68,
DRES/DBRD BURN LARGE,9000136,CDM,361,RC,16030,HCPCS,Outpatient,,,2763.45,2763.45,,1623.53,58.75,,1298.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,1623.53,58.75,,1298.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,1337.79,48.41,,1070.232,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,,Fee Schedule,100% of ASC Tier Groupings,1298.82,47,,1039.056,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,,Fee Schedule,100% of ASC Tier Groupings,1623.53,58.75,,1298.824,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,1298.82,47,,1039.056,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,1298.82,47,,1039.056,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,132.81,115,,,Fee Schedule,115% of CMS OPPS Rate,132.81,115,,,Fee Schedule,115% of CMS OPPS Rate,132.81,1623.53,
CURITY AMD PACKING STRIP 1/4,9000137,CDM,272,RC,,,Outpatient,,,7.10,7.10,,4.17,58.75,,3.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.17,58.75,,3.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.44,48.41,,2.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.39,90,,5.112,Percent of Total Billed Charges,90% of Total Billed Charges,6.39,90,,5.112,Percent of Total Billed Charges,90% of Total Billed Charges,3.34,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,6.39,90,,5.112,Percent of Total Billed Charges,90% of Total Billed Charges,4.17,58.75,,3.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.34,47,,2.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.34,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.34,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,3.34,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,3.34,6.39,
CURITY AMD PACKING STRIP 1/2,9000138,CDM,272,RC,,,Outpatient,,,7.10,7.10,,4.17,58.75,,3.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.17,58.75,,3.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.44,48.41,,2.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.39,90,,5.112,Percent of Total Billed Charges,90% of Total Billed Charges,6.39,90,,5.112,Percent of Total Billed Charges,90% of Total Billed Charges,3.34,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,6.39,90,,5.112,Percent of Total Billed Charges,90% of Total Billed Charges,4.17,58.75,,3.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.34,47,,2.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.34,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.34,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,3.34,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,3.34,6.39,
DRAWTEX 4X4,9000139,CDM,272,RC,,,Outpatient,,,27.65,27.65,,16.24,58.75,,12.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.24,58.75,,12.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.39,48.41,,10.712,Percent of Total Billed Charges,48.41% of Total Billed Charges,24.89,90,,19.912,Percent of Total Billed Charges,90% of Total Billed Charges,24.89,90,,19.912,Percent of Total Billed Charges,90% of Total Billed Charges,13,47,,10.4,Percent of Total Billed Charges,47% of Total Billed Charges,24.89,90,,19.912,Percent of Total Billed Charges,90% of Total Billed Charges,16.24,58.75,,12.992,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13,47,,10.4,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13,47,,10.4,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13,47,,10.4,Percent of Total Billed Charges,47% of Total Billed Charges,13,47,,10.4,Percent of Total Billed Charges,47% of Total Billed Charges,13,24.89,
GAUZE KERLEX 4.5,9000140,CDM,272,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
MEPILEX AG 4X4,9000141,CDM,272,RC,,,Outpatient,,,28.10,28.10,,16.51,58.75,,13.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,16.51,58.75,,13.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,13.6,48.41,,10.88,Percent of Total Billed Charges,48.41% of Total Billed Charges,25.29,90,,20.232,Percent of Total Billed Charges,90% of Total Billed Charges,25.29,90,,20.232,Percent of Total Billed Charges,90% of Total Billed Charges,13.21,47,,10.568,Percent of Total Billed Charges,47% of Total Billed Charges,25.29,90,,20.232,Percent of Total Billed Charges,90% of Total Billed Charges,16.51,58.75,,13.208,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.21,47,,10.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,13.21,47,,10.568,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,13.21,47,,10.568,Percent of Total Billed Charges,47% of Total Billed Charges,13.21,47,,10.568,Percent of Total Billed Charges,47% of Total Billed Charges,13.21,25.29,
ANTIMICROBIAL HYDROGEL,9000142,CDM,272,RC,,,Outpatient,,,61.05,61.05,,35.87,58.75,,28.696,Percent of Total Billed Charges,58.75% of Total Billed Charges,35.87,58.75,,28.696,Percent of Total Billed Charges,58.75% of Total Billed Charges,29.55,48.41,,23.64,Percent of Total Billed Charges,48.41% of Total Billed Charges,54.95,90,,43.96,Percent of Total Billed Charges,90% of Total Billed Charges,54.95,90,,43.96,Percent of Total Billed Charges,90% of Total Billed Charges,28.69,47,,22.952,Percent of Total Billed Charges,47% of Total Billed Charges,54.95,90,,43.96,Percent of Total Billed Charges,90% of Total Billed Charges,35.87,58.75,,28.696,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.69,47,,22.952,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,28.69,47,,22.952,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,28.69,47,,22.952,Percent of Total Billed Charges,47% of Total Billed Charges,28.69,47,,22.952,Percent of Total Billed Charges,47% of Total Billed Charges,28.69,54.95,
NUGAUZE 1 PLAIN,9000143,CDM,272,RC,,,Outpatient,,,7.10,7.10,,4.17,58.75,,3.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.17,58.75,,3.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.44,48.41,,2.752,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.39,90,,5.112,Percent of Total Billed Charges,90% of Total Billed Charges,6.39,90,,5.112,Percent of Total Billed Charges,90% of Total Billed Charges,3.34,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,6.39,90,,5.112,Percent of Total Billed Charges,90% of Total Billed Charges,4.17,58.75,,3.336,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.34,47,,2.672,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.34,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.34,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,3.34,47,,2.672,Percent of Total Billed Charges,47% of Total Billed Charges,3.34,6.39,
SALINE WOUND CLEANER,9000144,CDM,272,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
SKIN PREP,9000145,CDM,272,RC,,,Outpatient,,,2.00,2.00,,1.18,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,1.18,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,0.97,48.41,,0.776,Percent of Total Billed Charges,48.41% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,1.8,90,,1.44,Percent of Total Billed Charges,90% of Total Billed Charges,1.18,58.75,,0.944,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,47,,0.752,Percent of Total Billed Charges,47% of Total Billed Charges,0.94,1.8,
SORBION SACHET 4X4,9000146,CDM,272,RC,,,Outpatient,,,7.50,7.50,,4.41,58.75,,3.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,4.41,58.75,,3.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,3.63,48.41,,2.904,Percent of Total Billed Charges,48.41% of Total Billed Charges,6.75,90,,5.4,Percent of Total Billed Charges,90% of Total Billed Charges,6.75,90,,5.4,Percent of Total Billed Charges,90% of Total Billed Charges,3.53,47,,2.824,Percent of Total Billed Charges,47% of Total Billed Charges,6.75,90,,5.4,Percent of Total Billed Charges,90% of Total Billed Charges,4.41,58.75,,3.528,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.53,47,,2.824,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,3.53,47,,2.824,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,3.53,47,,2.824,Percent of Total Billed Charges,47% of Total Billed Charges,3.53,47,,2.824,Percent of Total Billed Charges,47% of Total Billed Charges,3.53,6.75,
SORBION SACHET 8X4,9000147,CDM,272,RC,,,Outpatient,,,12.25,12.25,,7.2,58.75,,5.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,7.2,58.75,,5.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,5.93,48.41,,4.744,Percent of Total Billed Charges,48.41% of Total Billed Charges,11.03,90,,8.824,Percent of Total Billed Charges,90% of Total Billed Charges,11.03,90,,8.824,Percent of Total Billed Charges,90% of Total Billed Charges,5.76,47,,4.608,Percent of Total Billed Charges,47% of Total Billed Charges,11.03,90,,8.824,Percent of Total Billed Charges,90% of Total Billed Charges,7.2,58.75,,5.76,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.76,47,,4.608,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,5.76,47,,4.608,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,5.76,47,,4.608,Percent of Total Billed Charges,47% of Total Billed Charges,5.76,47,,4.608,Percent of Total Billed Charges,47% of Total Billed Charges,5.76,11.03,
TIELLE 4X4,9000148,CDM,272,RC,,,Outpatient,,,36.50,36.50,,21.44,58.75,,17.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,21.44,58.75,,17.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,17.67,48.41,,14.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,32.85,90,,26.28,Percent of Total Billed Charges,90% of Total Billed Charges,32.85,90,,26.28,Percent of Total Billed Charges,90% of Total Billed Charges,17.16,47,,13.728,Percent of Total Billed Charges,47% of Total Billed Charges,32.85,90,,26.28,Percent of Total Billed Charges,90% of Total Billed Charges,21.44,58.75,,17.152,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.16,47,,13.728,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,17.16,47,,13.728,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,17.16,47,,13.728,Percent of Total Billed Charges,47% of Total Billed Charges,17.16,47,,13.728,Percent of Total Billed Charges,47% of Total Billed Charges,17.16,32.85,
DEBRIDE SUBQ TISSUE 1ST 20CM2,9000149,CDM,361,RC,11042,HCPCS,Outpatient,,,932.34,932.34,,547.75,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,547.75,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,451.35,48.41,,361.08,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,,Fee Schedule,100% of ASC Tier Groupings,438.2,47,,350.56,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,,Fee Schedule,100% of ASC Tier Groupings,547.75,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,145.5,100,,,Fee Schedule,100% of ASC Tier Groupings,438.2,47,,350.56,Percent of Total Billed Charges,47% of Total Billed charges,145.5,100,,,Fee Schedule,100% ASC Tier Groupings,438.2,47,,350.56,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,61.82,115,,,Fee Schedule,115% of CMS OPPS Rate,61.82,115,,,Fee Schedule,115% of CMS OPPS Rate,61.82,547.75,
DEBRIDE EA ADDL 20CM2,9000150,CDM,361,RC,11045,HCPCS,Outpatient,,,1464.51,1464.51,,860.4,58.75,,688.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,860.4,58.75,,688.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,708.97,48.41,,567.176,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,688.32,47,,550.656,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,860.4,58.75,,688.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,688.32,47,,550.656,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,688.32,47,,550.656,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,25.38,115,,,Fee Schedule,115% of CMS OPPS Rate,25.38,115,,,Fee Schedule,115% of CMS OPPS Rate,25.38,860.4,
"PUNCTURE ASPIRATION,ABSCESS HE",9000151,CDM,361,RC,10160,HCPCS,Outpatient,,,932.34,932.34,,547.75,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,547.75,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,451.35,48.41,,361.08,Percent of Total Billed Charges,48.41% of Total Billed Charges,349.44,100,,,fee Schedule,100% of ASC Tier Groupings ,349.44,100,,,Fee Schedule,100% of ASC Tier Groupings,438.2,47,,350.56,Percent of Total Billed Charges,47% of Total Billed Charges,349.44,100,,,Fee Schedule,100% of ASC Tier Groupings,547.75,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,66.9,100,,,Fee Schedule,100% of ASC Tier Groupings,438.2,47,,350.56,Percent of Total Billed Charges,47% of Total Billed charges,66.9,100,,,Fee Schedule,100% ASC Tier Groupings,438.2,47,,350.56,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,98.2,115,,,Fee Schedule,115% of CMS OPPS Rate,98.2,115,,,Fee Schedule,115% of CMS OPPS Rate,66.9,547.75,
APPLICATION OF RIDID CAST TCC,9000152,CDM,361,RC,29445,HCPCS,Outpatient,,,711.78,711.78,,418.17,58.75,,334.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,418.17,58.75,,334.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,344.57,48.41,,275.656,Percent of Total Billed Charges,48.41% of Total Billed Charges,252,100,,,fee Schedule,100% of ASC Tier Groupings ,252,100,,,Fee Schedule,100% of ASC Tier Groupings,334.54,47,,267.632,Percent of Total Billed Charges,47% of Total Billed Charges,252,100,,,Fee Schedule,100% of ASC Tier Groupings,418.17,58.75,,334.536,Percent of Total Billed Charges,58.75% of Total Billed Charges,48.88,100,,,Fee Schedule,100% of ASC Tier Groupings,334.54,47,,267.632,Percent of Total Billed Charges,47% of Total Billed charges,48.88,100,,,Fee Schedule,100% ASC Tier Groupings,334.54,47,,267.632,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,101.35,115,,,Fee Schedule,115% of CMS OPPS Rate,101.35,115,,,Fee Schedule,115% of CMS OPPS Rate,48.88,462,
NPWT TX 1/=50 S,9000153,CDM,361,RC,97607,HCPCS,Outpatient,,,932.34,932.34,,547.75,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,547.75,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,451.35,48.41,,361.08,Percent of Total Billed Charges,48.41% of Total Billed Charges,306.74,100,,,fee Schedule,100% of BCBS fee schedule,306.74,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,438.2,47,,350.56,Percent of Total Billed Charges,47% of Total Billed Charges,306.74,100,,,Fee Schedule,100% of BCBS PPO fee schedule,547.75,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,438.2,47,,350.56,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,438.2,47,,350.56,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,21.64,115,,,Fee Schedule,115% of CMS OPPS Rate,21.64,115,,,Fee Schedule,115% of CMS OPPS Rate,21.64,547.75,
NPWT TX > 50 C,9000154,CDM,361,RC,97608,HCPCS,Outpatient,,,932.34,932.34,,547.75,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,547.75,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,451.35,48.41,,361.08,Percent of Total Billed Charges,48.41% of Total Billed Charges,306.74,100,,,fee Schedule,100% of BCBS fee schedule,306.74,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,438.2,47,,350.56,Percent of Total Billed Charges,47% of Total Billed Charges,306.74,100,,,Fee Schedule,100% of BCBS PPO fee schedule,547.75,58.75,,438.2,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,438.2,47,,350.56,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,438.2,47,,350.56,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,24.73,115,,,Fee Schedule,115% of CMS OPPS Rate,24.73,115,,,Fee Schedule,115% of CMS OPPS Rate,24.73,547.75,
SKIN SUB GR LEG 1ST 25CM2 OR L,9000155,CDM,361,RC,15271,HCPCS,Outpatient,,,1491.06,1491.06,,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.82,48.41,,577.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,1774.08,100,,,fee Schedule,100% of ASC Tier Groupings ,1774.08,100,,,Fee Schedule,100% of ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,1774.08,100,,,Fee Schedule,100% of ASC Tier Groupings,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.01,100,,,Fee Schedule,100% of ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed charges,721.01,100,,,Fee Schedule,100% ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,620,100,,,Fee Schedule,100% of ASC Tier Groupings,85.76,115,,,Fee Schedule,115% of CMS OPPS Rate,85.76,115,,,Fee Schedule,115% of CMS OPPS Rate,85.76,1774.08,
SKIN SUB EA ADDL 25CM2,9000156,CDM,361,RC,15272,HCPCS,Outpatient,,,1491.06,1491.06,,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.82,48.41,,577.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,17.2,115,,,Fee Schedule,115% of CMS OPPS Rate,17.2,115,,,Fee Schedule,115% of CMS OPPS Rate,17.2,876,
SKIN SUB APP GR LEG 1ST 100C2,9000157,CDM,361,RC,15273,HCPCS,Outpatient,,,4988.22,4988.22,,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2414.8,48.41,,1931.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,3253.6,100,,,fee Schedule,100% of ASC Tier Groupings ,3253.6,100,,,Fee Schedule,100% of ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,3253.6,100,,,Fee Schedule,100% of ASC Tier Groupings,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,1482.27,100,,,Fee Schedule,100% of ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed charges,1482.27,100,,,Fee Schedule,100% ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,1302,100,,,Fee Schedule,100% of ASC Tier Groupings,195.43,115,,,Fee Schedule,115% of CMS OPPS Rate,195.43,115,,,Fee Schedule,115% of CMS OPPS Rate,195.43,3253.6,
SKIN SUB EA ADDL 100CM2,9000158,CDM,361,RC,15274,HCPCS,Outpatient,,,4988.22,4988.22,,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2414.8,48.41,,1931.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,44.03,115,,,Fee Schedule,115% of CMS OPPS Rate,44.03,115,,,Fee Schedule,115% of CMS OPPS Rate,44.03,2930.58,
SKIN SUB APP GR FT 1ST 25CM2,9000159,CDM,361,RC,15275,HCPCS,Outpatient,,,1491.06,1491.06,,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.82,48.41,,577.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,1774.08,100,,,fee Schedule,100% of ASC Tier Groupings ,1774.08,100,,,Fee Schedule,100% of ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,1774.08,100,,,Fee Schedule,100% of ASC Tier Groupings,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.01,100,,,Fee Schedule,100% of ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed charges,721.01,100,,,Fee Schedule,100% ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,620,100,,,Fee Schedule,100% of ASC Tier Groupings,96.81,115,,,Fee Schedule,115% of CMS OPPS Rate,96.81,115,,,Fee Schedule,115% of CMS OPPS Rate,96.81,1774.08,
SKIN SUB EA ADDL 25CM2,9000160,CDM,361,RC,15276,HCPCS,Outpatient,,,1491.06,1491.06,,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.82,48.41,,577.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,25.51,115,,,Fee Schedule,115% of CMS OPPS Rate,25.51,115,,,Fee Schedule,115% of CMS OPPS Rate,25.51,876,
SKIN SUB APP GR FT 1ST 100CM2,9000161,CDM,361,RC,15277,HCPCS,Outpatient,,,1491.06,1491.06,,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.82,48.41,,577.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,1774.08,100,,,fee Schedule,100% of ASC Tier Groupings ,1774.08,100,,,Fee Schedule,100% of ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,1774.08,100,,,Fee Schedule,100% of ASC Tier Groupings,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.01,100,,,Fee Schedule,100% of ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed charges,721.01,100,,,Fee Schedule,100% ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,620,100,,,Fee Schedule,100% of ASC Tier Groupings,225.17,115,,,Fee Schedule,115% of CMS OPPS Rate,225.17,115,,,Fee Schedule,115% of CMS OPPS Rate,225.17,1774.08,
SKIN SUB EA ADDL 100 CM2,9000162,CDM,361,RC,15278,HCPCS,Outpatient,,,1491.06,1491.06,,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.82,48.41,,577.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,55.96,115,,,Fee Schedule,115% of CMS OPPS Rate,55.96,115,,,Fee Schedule,115% of CMS OPPS Rate,55.96,876,
DEBRIDE MUS/FASC 1ST 20CM2,9000163,CDM,361,RC,11043,HCPCS,Outpatient,,,1464.51,1464.51,,860.4,58.75,,688.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,860.4,58.75,,688.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,708.97,48.41,,567.176,Percent of Total Billed Charges,48.41% of Total Billed Charges,543.2,100,,,fee Schedule,100% of ASC Tier Groupings ,543.2,100,,,Fee Schedule,100% of ASC Tier Groupings,688.32,47,,550.656,Percent of Total Billed Charges,47% of Total Billed Charges,543.2,100,,,Fee Schedule,100% of ASC Tier Groupings,860.4,58.75,,688.32,Percent of Total Billed Charges,58.75% of Total Billed Charges,220.47,100,,,Fee Schedule,100% of ASC Tier Groupings,688.32,47,,550.656,Percent of Total Billed Charges,47% of Total Billed charges,220.47,100,,,Fee Schedule,100% ASC Tier Groupings,688.32,47,,550.656,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,156.5,115,,,Fee Schedule,115% of CMS OPPS Rate,156.5,115,,,Fee Schedule,115% of CMS OPPS Rate,156.5,860.4,
DEBRIDE BONE 1ST 20CM2,9000164,CDM,361,RC,11044,HCPCS,Outpatient,,,4043.82,4043.82,,2375.74,58.75,,1900.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,2375.74,58.75,,1900.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,1957.61,48.41,,1566.088,Percent of Total Billed Charges,48.41% of Total Billed Charges,1500.8,100,,,fee Schedule,100% of ASC Tier Groupings ,1500.8,100,,,Fee Schedule,100% of ASC Tier Groupings,1900.6,47,,1520.48,Percent of Total Billed Charges,47% of Total Billed Charges,1500.8,100,,,Fee Schedule,100% of ASC Tier Groupings,2375.74,58.75,,1900.592,Percent of Total Billed Charges,58.75% of Total Billed Charges,494.68,100,,,Fee Schedule,100% of ASC Tier Groupings,1900.6,47,,1520.48,Percent of Total Billed Charges,47% of Total Billed charges,494.68,100,,,Fee Schedule,100% ASC Tier Groupings,1900.6,47,,1520.48,Percent of Total Billed Charges,47% of Total Billed Charges,475,100,,,Fee Schedule,100% of ASC Tier Groupings,228.51,115,,,Fee Schedule,115% of CMS OPPS Rate,228.51,115,,,Fee Schedule,115% of CMS OPPS Rate,228.51,2375.74,
AP SBSSKN TAL100 CM W 1ST 25CM,9000165,CDM,361,RC,15271,HCPCS,Outpatient,,,4988.22,4988.22,,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2414.8,48.41,,1931.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,1774.08,100,,,fee Schedule,100% of ASC Tier Groupings ,1774.08,100,,,Fee Schedule,100% of ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,1774.08,100,,,Fee Schedule,100% of ASC Tier Groupings,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.01,100,,,Fee Schedule,100% of ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed charges,721.01,100,,,Fee Schedule,100% ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,620,100,,,Fee Schedule,100% of ASC Tier Groupings,85.76,115,,,Fee Schedule,115% of CMS OPPS Rate,85.76,115,,,Fee Schedule,115% of CMS OPPS Rate,85.76,2930.58,
AP SBSSKN TAL 100CM W ADL 25CM,9000166,CDM,361,RC,15272,HCPCS,Outpatient,,,4988.22,4988.22,,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2414.8,48.41,,1931.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,17.2,115,,,Fee Schedule,115% of CMS OPPS Rate,17.2,115,,,Fee Schedule,115% of CMS OPPS Rate,17.2,2930.58,
AP SKNSBS TAL>=100CM W1ST100CM,9000167,CDM,361,RC,15273,HCPCS,Outpatient,,,8931.87,8931.87,,5247.47,58.75,,4197.976,Percent of Total Billed Charges,58.75% of Total Billed Charges,5247.47,58.75,,4197.976,Percent of Total Billed Charges,58.75% of Total Billed Charges,4323.92,48.41,,3459.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,3253.6,100,,,fee Schedule,100% of ASC Tier Groupings ,3253.6,100,,,Fee Schedule,100% of ASC Tier Groupings,4197.98,47,,3358.384,Percent of Total Billed Charges,47% of Total Billed Charges,3253.6,100,,,Fee Schedule,100% of ASC Tier Groupings,5247.47,58.75,,4197.976,Percent of Total Billed Charges,58.75% of Total Billed Charges,1482.27,100,,,Fee Schedule,100% of ASC Tier Groupings,4197.98,47,,3358.384,Percent of Total Billed Charges,47% of Total Billed charges,1482.27,100,,,Fee Schedule,100% ASC Tier Groupings,4197.98,47,,3358.384,Percent of Total Billed Charges,47% of Total Billed Charges,1302,100,,,Fee Schedule,100% of ASC Tier Groupings,195.43,115,,,Fee Schedule,115% of CMS OPPS Rate,195.43,115,,,Fee Schedule,115% of CMS OPPS Rate,195.43,5247.47,
AP SKNSBS TAL>=100CMWADDL100CM,9000168,CDM,361,RC,15274,HCPCS,Outpatient,,,8931.87,8931.87,,5247.47,58.75,,4197.976,Percent of Total Billed Charges,58.75% of Total Billed Charges,5247.47,58.75,,4197.976,Percent of Total Billed Charges,58.75% of Total Billed Charges,4323.92,48.41,,3459.136,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4197.98,47,,3358.384,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,5247.47,58.75,,4197.976,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,4197.98,47,,3358.384,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,4197.98,47,,3358.384,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,44.03,115,,,Fee Schedule,115% of CMS OPPS Rate,44.03,115,,,Fee Schedule,115% of CMS OPPS Rate,44.03,5247.47,
SBSN FSHNDFTGEN 100CMW1ST 25CM,9000169,CDM,361,RC,15275,HCPCS,Outpatient,,,4988.22,4988.22,,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2414.8,48.41,,1931.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,1774.08,100,,,fee Schedule,100% of ASC Tier Groupings ,1774.08,100,,,Fee Schedule,100% of ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,1774.08,100,,,Fee Schedule,100% of ASC Tier Groupings,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.01,100,,,Fee Schedule,100% of ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed charges,721.01,100,,,Fee Schedule,100% ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,620,100,,,Fee Schedule,100% of ASC Tier Groupings,96.81,115,,,Fee Schedule,115% of CMS OPPS Rate,96.81,115,,,Fee Schedule,115% of CMS OPPS Rate,96.81,2930.58,
APP SKIN SUB/EA ADDL 25 CM,9000170,CDM,361,RC,15276,HCPCS,Outpatient,,,4988.22,4988.22,,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2414.8,48.41,,1931.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,25.51,115,,,Fee Schedule,115% of CMS OPPS Rate,25.51,115,,,Fee Schedule,115% of CMS OPPS Rate,25.51,2930.58,
SNSBFDHNDFTGEN>=100CMW1ST100CM,9000171,CDM,361,RC,15277,HCPCS,Outpatient,,,4988.22,4988.22,,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2414.8,48.41,,1931.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,1774.08,100,,,fee Schedule,100% of ASC Tier Groupings ,1774.08,100,,,Fee Schedule,100% of ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,1774.08,100,,,Fee Schedule,100% of ASC Tier Groupings,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.01,100,,,Fee Schedule,100% of ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed charges,721.01,100,,,Fee Schedule,100% ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,620,100,,,Fee Schedule,100% of ASC Tier Groupings,225.17,115,,,Fee Schedule,115% of CMS OPPS Rate,225.17,115,,,Fee Schedule,115% of CMS OPPS Rate,225.17,2930.58,
SKSBFDHNDFTGEN>100CMWADDL100CM,9000172,CDM,361,RC,15278,HCPCS,Outpatient,,,4988.22,4988.22,,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2414.8,48.41,,1931.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,55.96,115,,,Fee Schedule,115% of CMS OPPS Rate,55.96,115,,,Fee Schedule,115% of CMS OPPS Rate,55.96,2930.58,
AP SBS SKN TAL 100CM 1ST 25CM,9000173,CDM,361,RC,C5271,HCPCS,Outpatient,,,1491.06,1491.06,,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.82,48.41,,577.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,1341.95,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,1341.95,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,1341.95,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,220.47,100,,,Fee Schedule,100% of ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed charges,220.47,100,,,Fee Schedule,100% ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,220.47,1341.95,
AP SBS SKN TAL 100CM ADL 25CM,9000174,CDM,361,RC,C5272,HCPCS,Outpatient,,,1491.06,1491.06,,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.82,48.41,,577.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,1341.95,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,1341.95,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,1341.95,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,462,1341.95,
AP SKN SBS TAL>=100CMW1SR100CM,9000175,CDM,361,RC,C5273,HCPCS,Outpatient,,,4988.22,4988.22,,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2414.8,48.41,,1931.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,4489.4,90,,3591.52,Percent of Total Billed Charges,90% of Total Billed Charges,4489.4,90,,3591.52,Percent of Total Billed Charges,90% of Total Billed Charges,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,4489.4,90,,3591.52,Percent of Total Billed Charges,90% of Total Billed Charges,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.01,100,,,Fee Schedule,100% of ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed charges,721.01,100,,,Fee Schedule,100% ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,620,100,,,Fee Schedule,100% of ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,620,4489.4,
AP SKNSBS TAL>=100CMWADL 100CM,9000176,CDM,361,RC,C5274,HCPCS,Outpatient,,,4988.22,4988.22,,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,2414.8,48.41,,1931.84,Percent of Total Billed Charges,48.41% of Total Billed Charges,4489.4,90,,3591.52,Percent of Total Billed Charges,90% of Total Billed Charges,4489.4,90,,3591.52,Percent of Total Billed Charges,90% of Total Billed Charges,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,4489.4,90,,3591.52,Percent of Total Billed Charges,90% of Total Billed Charges,2930.58,58.75,,2344.464,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,2344.46,47,,1875.568,Percent of Total Billed Charges,47% of Total Billed Charges,462,4489.4,
SBSSKNFSHNDFTGEN100CMW1ST25CM,9000177,CDM,361,RC,C5275,HCPCS,Outpatient,,,1491.06,1491.06,,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.82,48.41,,577.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,1341.95,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,1341.95,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,1341.95,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,220.47,100,,,Fee Schedule,100% of ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed charges,220.47,100,,,Fee Schedule,100% ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,220.47,1341.95,
APP SJUB SUB/EA ADDL 25 CM,9000178,CDM,361,RC,C5276,HCPCS,Outpatient,,,1491.06,1491.06,,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.82,48.41,,577.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,1341.95,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,1341.95,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,1341.95,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,462,1341.95,
SSFDHNDFTGEB>=100CMW 1ST100CM,9000179,CDM,361,RC,C5277,HCPCS,Outpatient,,,1491.06,1491.06,,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.82,48.41,,577.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,1341.95,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,1341.95,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,1341.95,90,,1073.56,Percent of Total Billed Charges,90% of Total Billed Charges,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,220.47,100,,,Fee Schedule,100% of ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed charges,220.47,100,,,Fee Schedule,100% ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,220.47,1341.95,
SKNSBFDHNDFTGEN>100CMWADL100CM,9000180,CDM,361,RC,15278,HCPCS,Outpatient,,,1491.06,1491.06,,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,721.82,48.41,,577.456,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,876,58.75,,700.8,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,700.8,47,,560.64,Percent of Total Billed Charges,47% of Total Billed Charges,462,100,,,Fee Schedule,100% of ASC Tier Groupings,55.96,115,,,Fee Schedule,115% of CMS OPPS Rate,55.96,115,,,Fee Schedule,115% of CMS OPPS Rate,55.96,876,
PURAPLY 1 SQ.CM,9000181,CDM,636,RC,Q4195,HCPCS,Outpatient,,,391.88,391.88,,230.23,58.75,,184.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,230.23,58.75,,184.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,189.71,48.41,,151.768,Percent of Total Billed Charges,48.41% of Total Billed Charges,352.69,90,,282.152,Percent of Total Billed Charges,90% of Total Billed Charges,352.69,90,,282.152,Percent of Total Billed Charges,90% of Total Billed Charges,184.18,47,,147.344,Percent of Total Billed Charges,47% of Total Billed Charges,352.69,90,,282.152,Percent of Total Billed Charges,90% of Total Billed Charges,230.23,58.75,,184.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,184.18,47,,147.344,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,184.18,47,,147.344,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,184.18,47,,147.344,Percent of Total Billed Charges,47% of Total Billed Charges,184.18,47,,147.344,Percent of Total Billed Charges,47% of Total Billed Charges,184.18,352.69,
PURAPLY AM 1 SQ.CM,9000183,CDM,636,RC,Q4196,HCPCS,Outpatient,,,681.00,681.00,,400.09,58.75,,320.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,400.09,58.75,,320.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,329.67,48.41,,263.736,Percent of Total Billed Charges,48.41% of Total Billed Charges,612.9,90,,490.32,Percent of Total Billed Charges,90% of Total Billed Charges,612.9,90,,490.32,Percent of Total Billed Charges,90% of Total Billed Charges,320.07,47,,256.056,Percent of Total Billed Charges,47% of Total Billed Charges,612.9,90,,490.32,Percent of Total Billed Charges,90% of Total Billed Charges,400.09,58.75,,320.072,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,320.07,47,,256.056,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,320.07,47,,256.056,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,320.07,47,,256.056,Percent of Total Billed Charges,47% of Total Billed Charges,320.07,47,,256.056,Percent of Total Billed Charges,47% of Total Billed Charges,320.07,612.9,
PURAPLY AM 1.6,9000186,CDM,636,RC,Q4196,HCPCS,Outpatient,,,1395.00,1395.00,,819.56,58.75,,655.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,819.56,58.75,,655.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,675.32,48.41,,540.256,Percent of Total Billed Charges,48.41% of Total Billed Charges,1255.5,90,,1004.4,Percent of Total Billed Charges,90% of Total Billed Charges,1255.5,90,,1004.4,Percent of Total Billed Charges,90% of Total Billed Charges,655.65,47,,524.52,Percent of Total Billed Charges,47% of Total Billed Charges,1255.5,90,,1004.4,Percent of Total Billed Charges,90% of Total Billed Charges,819.56,58.75,,655.648,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,655.65,47,,524.52,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,655.65,47,,524.52,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,655.65,47,,524.52,Percent of Total Billed Charges,47% of Total Billed Charges,655.65,47,,524.52,Percent of Total Billed Charges,47% of Total Billed Charges,655.65,1255.5,
APLIGRAF 1 SQ.CM,9000187,CDM,636,RC,Q4101,HCPCS,Outpatient,,,97.15,97.15,,57.08,58.75,,45.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,57.08,58.75,,45.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,47.03,48.41,,37.624,Percent of Total Billed Charges,48.41% of Total Billed Charges,87.44,90,,69.952,Percent of Total Billed Charges,90% of Total Billed Charges,87.44,90,,69.952,Percent of Total Billed Charges,90% of Total Billed Charges,45.66,47,,36.528,Percent of Total Billed Charges,47% of Total Billed Charges,87.44,90,,69.952,Percent of Total Billed Charges,90% of Total Billed Charges,57.08,58.75,,45.664,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.66,47,,36.528,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,45.66,47,,36.528,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,45.66,47,,36.528,Percent of Total Billed Charges,47% of Total Billed Charges,45.66,47,,36.528,Percent of Total Billed Charges,47% of Total Billed Charges,45.66,87.44,
NUSHIELD 1.6 DISC,9000188,CDM,636,RC,Q4160,HCPCS,Outpatient,,,1224.50,1224.50,,719.39,58.75,,575.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,719.39,58.75,,575.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,592.78,48.41,,474.224,Percent of Total Billed Charges,48.41% of Total Billed Charges,1102.05,90,,881.64,Percent of Total Billed Charges,90% of Total Billed Charges,1102.05,90,,881.64,Percent of Total Billed Charges,90% of Total Billed Charges,575.52,47,,460.416,Percent of Total Billed Charges,47% of Total Billed Charges,1102.05,90,,881.64,Percent of Total Billed Charges,90% of Total Billed Charges,719.39,58.75,,575.512,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,575.52,47,,460.416,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,575.52,47,,460.416,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,575.52,47,,460.416,Percent of Total Billed Charges,47% of Total Billed Charges,575.52,47,,460.416,Percent of Total Billed Charges,47% of Total Billed Charges,575.52,1102.05,
NUSHIELD 1 SQ.CM,9000191,CDM,636,RC,Q4160,HCPCS,Outpatient,,,385.01,385.01,,226.19,58.75,,180.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,226.19,58.75,,180.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,186.38,48.41,,149.104,Percent of Total Billed Charges,48.41% of Total Billed Charges,346.51,90,,277.208,Percent of Total Billed Charges,90% of Total Billed Charges,346.51,90,,277.208,Percent of Total Billed Charges,90% of Total Billed Charges,180.95,47,,144.76,Percent of Total Billed Charges,47% of Total Billed Charges,346.51,90,,277.208,Percent of Total Billed Charges,90% of Total Billed Charges,226.19,58.75,,180.952,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,180.95,47,,144.76,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,180.95,47,,144.76,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,180.95,47,,144.76,Percent of Total Billed Charges,47% of Total Billed Charges,180.95,47,,144.76,Percent of Total Billed Charges,47% of Total Billed Charges,180.95,346.51,
NON SELECTIVE DEBRIDMENT,9000195,CDM,361,RC,97602,HCPCS,Outpatient,,,274.32,274.32,,161.16,58.75,,128.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,161.16,58.75,,128.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,132.8,48.41,,106.24,Percent of Total Billed Charges,48.41% of Total Billed Charges,167.75,100,,,fee Schedule,100% of BCBS fee schedule,167.75,100,,,Fee Schedule,100% of BCBS Health Advantage HMO fee schedule,128.93,47,,103.144,Percent of Total Billed Charges,47% of Total Billed Charges,167.75,100,,,Fee Schedule,100% of BCBS PPO fee schedule,161.16,58.75,,128.928,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,128.93,47,,103.144,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,128.93,47,,103.144,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,128.93,47,,103.144,Percent of Total Billed Charges,47% of Total Billed Charges,128.93,47,,103.144,Percent of Total Billed Charges,47% of Total Billed Charges,128.93,167.75,
AFFINITY 1 SQ.CM,9000196,CDM,636,RC,Q4159,HCPCS,Outpatient,,,1980.00,1980.00,,1163.25,58.75,,930.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,1163.25,58.75,,930.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,958.52,48.41,,766.816,Percent of Total Billed Charges,48.41% of Total Billed Charges,1782,90,,1425.6,Percent of Total Billed Charges,90% of Total Billed Charges,1782,90,,1425.6,Percent of Total Billed Charges,90% of Total Billed Charges,930.6,47,,744.48,Percent of Total Billed Charges,47% of Total Billed Charges,1782,90,,1425.6,Percent of Total Billed Charges,90% of Total Billed Charges,1163.25,58.75,,930.6,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,930.6,47,,744.48,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,930.6,47,,744.48,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,930.6,47,,744.48,Percent of Total Billed Charges,47% of Total Billed Charges,930.6,47,,744.48,Percent of Total Billed Charges,47% of Total Billed Charges,930.6,1782,
PURAPLY AN XT 1 SQ.CM,9000197,CDM,636,RC,Q4197,HCPCS,Outpatient,,,363.00,363.00,,213.26,58.75,,170.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,213.26,58.75,,170.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,175.73,48.41,,140.584,Percent of Total Billed Charges,48.41% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,170.61,47,,136.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately Reimbursable,213.26,58.75,,170.608,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,170.61,47,,136.488,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,170.61,47,,136.488,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,170.61,47,,136.488,Percent of Total Billed Charges,47% of Total Billed Charges,170.61,47,,136.488,Percent of Total Billed Charges,47% of Total Billed Charges,170.61,213.26,
Kerecis Omega3 Shield 1 sq cm,9000198,CDM,272,RC,A2019,HCPCS,Outpatient,,,2241.00,2241.00,,1316.59,58.75,,1053.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,1316.59,58.75,,1053.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,1084.87,48.41,,867.896,Percent of Total Billed Charges,48.41% of Total Billed Charges,2016.9,90,,1613.52,Percent of Total Billed Charges,90% of Total Billed Charges,2016.9,90,,1613.52,Percent of Total Billed Charges,90% of Total Billed Charges,1053.27,47,,842.616,Percent of Total Billed Charges,47% of Total Billed Charges,2016.9,90,,1613.52,Percent of Total Billed Charges,90% of Total Billed Charges,1316.59,58.75,,1053.272,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1053.27,47,,842.616,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,1053.27,47,,842.616,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,1053.27,47,,842.616,Percent of Total Billed Charges,47% of Total Billed Charges,1053.27,47,,842.616,Percent of Total Billed Charges,47% of Total Billed Charges,1053.27,2016.9,
Kerecis Omega3 Marigen 1 sq cm,9000199,CDM,636,RC,Q4158,HCPCS,Outpatient,,,594.00,594.00,,348.98,58.75,,279.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,348.98,58.75,,279.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,287.56,48.41,,230.048,Percent of Total Billed Charges,48.41% of Total Billed Charges,534.6,90,,427.68,Percent of Total Billed Charges,90% of Total Billed Charges,534.6,90,,427.68,Percent of Total Billed Charges,90% of Total Billed Charges,279.18,47,,223.344,Percent of Total Billed Charges,47% of Total Billed Charges,534.6,90,,427.68,Percent of Total Billed Charges,90% of Total Billed Charges,348.98,58.75,,279.184,Percent of Total Billed Charges,58.75% of Total Billed Charges,,,,,Other,Not Separately reimbursable,279.18,47,,223.344,Percent of Total Billed Charges,47% of Total Billed charges,,,,,Other,Not Separately Reimbursable,279.18,47,,223.344,Percent of Total Billed Charges,47% of Total Billed Charges,,,,,Other,Not Separately reimbursable,279.18,47,,223.344,Percent of Total Billed Charges,47% of Total Billed Charges,279.18,47,,223.344,Percent of Total Billed Charges,47% of Total Billed Charges,279.18,534.6,
SEMI PRIVATE ROOM,990001,CDM,120,RC,,,Inpatient,,,576.00,576.00,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per diem,Pays based on per day rate,2846,100,,,Per diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SWING BED,9900016,CDM,120,RC,,,Inpatient,,,382.00,382.00,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per diem,Pays based on per day rate,2846,100,,,Per diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
TELEMETRY ROOM,9900020,CDM,160,RC,,,Inpatient,,,764.00,764.00,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per diem,Pays based on per day rate,2846,100,,,Per diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ISOLATION ROOM,9900021,CDM,160,RC,,,Inpatient,,,694.10,694.10,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per diem,Pays based on per day rate,2846,100,,,Per diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DUMMY CODE,9999999,CDM,167,RC,,,Inpatient,,,1.00,1.00,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per diem,Pays based on per day rate,2846,100,,,Per diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,,,,,Other,Not Separately reimbursable,2277,100,,,Per Diem,Pays based on per day rate,2277,115,,,Case Rate,Pays based on per visit rate,2235,3514,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,1,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,2,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",3,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",4,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,5,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LIVER TRANSPLANT WITHOUT MCC,6,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LUNG TRANSPLANT,7,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,8,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PANCREAS TRANSPLANT,10,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",11,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",12,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",13,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ALLOGENEIC BONE MARROW TRANSPLANT,14,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,16,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,17,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,18,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,19,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,20,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,21,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,22,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,23,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,24,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,25,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,26,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,27,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SPINAL PROCEDURES WITH MCC,28,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,29,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SPINAL PROCEDURES WITHOUT CC/MCC,30,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
VENTRICULAR SHUNT PROCEDURES WITH MCC,31,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
VENTRICULAR SHUNT PROCEDURES WITH CC,32,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,33,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CAROTID ARTERY STENT PROCEDURES WITH MCC,34,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CAROTID ARTERY STENT PROCEDURES WITH CC,35,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,36,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
EXTRACRANIAL PROCEDURES WITH MCC,37,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
EXTRACRANIAL PROCEDURES WITH CC,38,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,39,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",40,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",41,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",42,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,52,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,53,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NERVOUS SYSTEM NEOPLASMS WITH MCC,54,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,55,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,56,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,57,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,58,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,59,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,60,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",61,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",62,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",63,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,64,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,65,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,66,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,67,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,68,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,69,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,70,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,71,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,72,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,73,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,74,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
VIRAL MENINGITIS WITH CC/MCC,75,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
VIRAL MENINGITIS WITHOUT CC/MCC,76,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HYPERTENSIVE ENCEPHALOPATHY WITH MCC,77,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HYPERTENSIVE ENCEPHALOPATHY WITH CC,78,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,79,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NONTRAUMATIC STUPOR AND COMA WITH MCC,80,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,81,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,82,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,83,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,84,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,85,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,86,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,87,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CONCUSSION WITH MCC,88,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CONCUSSION WITH CC,89,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CONCUSSION WITHOUT CC/MCC,90,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,91,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,92,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,93,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,94,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,95,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,96,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,97,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,98,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,99,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SEIZURES WITH MCC,100,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SEIZURES WITHOUT MCC,101,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HEADACHES WITH MCC,102,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HEADACHES WITHOUT MCC,103,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ORBITAL PROCEDURES WITH CC/MCC,113,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NEUROLOGICAL EYE DISORDERS,123,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MOUTH PROCEDURES WITH CC/MCC,137,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MOUTH PROCEDURES WITHOUT CC/MCC,138,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SALIVARY GLAND PROCEDURES,139,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DYSEQUILIBRIUM,149,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
EPISTAXIS WITH MCC,150,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
EPISTAXIS WITHOUT MCC,151,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTITIS MEDIA AND URI WITH MCC,152,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTITIS MEDIA AND URI WITHOUT MCC,153,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DENTAL AND ORAL DISEASES WITH MCC,157,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DENTAL AND ORAL DISEASES WITH CC,158,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR CHEST PROCEDURES WITH MCC,163,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR CHEST PROCEDURES WITH CC,164,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PULMONARY EMBOLISM WITHOUT MCC,176,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RESPIRATORY NEOPLASMS WITH MCC,180,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RESPIRATORY NEOPLASMS WITH CC,181,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR CHEST TRAUMA WITH MCC,183,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR CHEST TRAUMA WITH CC,184,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PLEURAL EFFUSION WITH MCC,186,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PLEURAL EFFUSION WITH CC,187,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PLEURAL EFFUSION WITHOUT CC/MCC,188,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INTERSTITIAL LUNG DISEASE WITH MCC,196,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INTERSTITIAL LUNG DISEASE WITH CC,197,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PNEUMOTHORAX WITH MCC,199,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PNEUMOTHORAX WITH CC,200,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PNEUMOTHORAX WITHOUT CC/MCC,201,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RESPIRATORY SIGNS AND SYMPTOMS,204,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER HEART ASSIST SYSTEM IMPLANT,215,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CORONARY BYPASS WITH PTCA WITH MCC,231,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
AICD GENERATOR PROCEDURES,245,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER VASCULAR PROCEDURES WITH MCC,252,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER VASCULAR PROCEDURES WITH CC,253,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
VEIN LIGATION AND STRIPPING,263,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
AICD LEAD PROCEDURES,265,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HEART FAILURE AND SHOCK WITH MCC,291,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HEART FAILURE AND SHOCK WITH CC,292,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,294,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,295,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ATHEROSCLEROSIS WITH MCC,302,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ATHEROSCLEROSIS WITHOUT MCC,303,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HYPERTENSION WITH MCC,304,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HYPERTENSION WITHOUT MCC,305,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ANGINA PECTORIS,311,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SYNCOPE AND COLLAPSE,312,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CHEST PAIN,313,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RECTAL RESECTION WITH MCC,332,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RECTAL RESECTION WITH CC,333,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RECTAL RESECTION WITHOUT CC/MCC,334,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PERITONEAL ADHESIOLYSIS WITH MCC,335,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PERITONEAL ADHESIOLYSIS WITH CC,336,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ANAL AND STOMAL PROCEDURES WITH MCC,347,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ANAL AND STOMAL PROCEDURES WITH CC,348,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DIGESTIVE MALIGNANCY WITH MCC,374,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DIGESTIVE MALIGNANCY WITH CC,375,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
COMPLICATED PEPTIC ULCER WITH MCC,380,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
COMPLICATED PEPTIC ULCER WITH CC,381,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INFLAMMATORY BOWEL DISEASE WITH CC,386,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
APPENDIX PROCEDURES WITH MCC,397,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
APPENDIX PROCEDURES WITH CC,398,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DISORDERS OF THE BILIARY TRACT WITH CC,445,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CERVICAL SPINAL FUSION WITH MCC,471,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CERVICAL SPINAL FUSION WITH CC,472,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SOFT TISSUE PROCEDURES WITH MCC,500,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SOFT TISSUE PROCEDURES WITH CC,501,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
FOOT PROCEDURES WITH MCC,503,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
FOOT PROCEDURES WITH CC,504,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
FOOT PROCEDURES WITHOUT CC/MCC,505,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR THUMB OR JOINT PROCEDURES,506,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ARTHROSCOPY,509,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
FRACTURES OF FEMUR WITH MCC,533,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
FRACTURES OF FEMUR WITHOUT MCC,534,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
FRACTURES OF HIP AND PELVIS WITH MCC,535,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OSTEOMYELITIS WITH MCC,539,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OSTEOMYELITIS WITH CC,540,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OSTEOMYELITIS WITHOUT CC/MCC,541,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CONNECTIVE TISSUE DISORDERS WITH CC,546,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SEPTIC ARTHRITIS WITH MCC,548,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SEPTIC ARTHRITIS WITH CC,549,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MEDICAL BACK PROBLEMS WITH MCC,551,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SKIN DEBRIDEMENT WITH MCC,570,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SKIN DEBRIDEMENT WITH CC,571,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SKIN ULCERS WITH MCC,592,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SKIN ULCERS WITH CC,593,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SKIN ULCERS WITHOUT CC/MCC,594,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR SKIN DISORDERS WITH MCC,595,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR SKIN DISORDERS WITHOUT MCC,596,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MALIGNANT BREAST DISORDERS WITH MCC,597,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MALIGNANT BREAST DISORDERS WITH CC,598,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CELLULITIS WITH MCC,602,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CELLULITIS WITHOUT MCC,603,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MINOR SKIN DISORDERS WITH MCC,606,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MINOR SKIN DISORDERS WITHOUT MCC,607,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
O.R. PROCEDURES FOR OBESITY WITH CC,620,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DIABETES WITH MCC,637,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DIABETES WITH CC,638,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DIABETES WITHOUT CC/MCC,639,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INBORN AND OTHER DISORDERS OF METABOLISM,642,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ENDOCRINE DISORDERS WITH MCC,643,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ENDOCRINE DISORDERS WITH CC,644,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KIDNEY TRANSPLANT,652,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR BLADDER PROCEDURES WITH MCC,653,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR BLADDER PROCEDURES WITH CC,654,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MINOR BLADDER PROCEDURES WITH MCC,662,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MINOR BLADDER PROCEDURES WITH CC,663,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PROSTATECTOMY WITH MCC,665,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PROSTATECTOMY WITH CC,666,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PROSTATECTOMY WITHOUT CC/MCC,667,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
TRANSURETHRAL PROCEDURES WITH MCC,668,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
TRANSURETHRAL PROCEDURES WITH CC,669,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
URETHRAL PROCEDURES WITH CC/MCC,671,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RENAL FAILURE WITH MCC,682,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RENAL FAILURE WITH CC,683,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RENAL FAILURE WITHOUT CC/MCC,684,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
URINARY STONES WITH MCC,693,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
URINARY STONES WITHOUT MCC,694,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
URETHRAL STRICTURE,697,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PENIS PROCEDURES WITH CC/MCC,709,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PENIS PROCEDURES WITHOUT CC/MCC,710,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
TESTES PROCEDURES WITH CC/MCC,711,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
TESTES PROCEDURES WITHOUT CC/MCC,712,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,1785,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,1785,3514,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ABORTION WITHOUT D&C,779,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2310,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2235,3514,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2310,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2235,3514,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2310,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2235,3514,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2310,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2235,3514,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2310,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2235,3514,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2310,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2235,3514,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PREMATURITY WITH MAJOR PROBLEMS,791,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NORMAL NEWBORN,795,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,1785,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,1785,3514,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,1785,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,1785,3514,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,1785,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,1785,3514,
SPLENIC PROCEDURES WITH MCC,799,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SPLENIC PROCEDURES WITH CC,800,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,1785,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,1785,3514,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,1785,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,1785,3514,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,1785,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,1785,3514,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RED BLOOD CELL DISORDERS WITH MCC,811,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
COAGULATION DISORDERS,813,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,446,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,446,3514,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,446,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,446,3514,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,446,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,446,3514,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,446,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,446,3514,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,446,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,446,3514,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,446,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,446,3514,
ACUTE LEUKEMIA WITH MCC,834,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ACUTE LEUKEMIA WITH CC,835,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ACUTE LEUKEMIA WITHOUT CC/MCC,836,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
RADIOTHERAPY,849,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
FEVER AND INFLAMMATORY CONDITIONS,864,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
VIRAL ILLNESS WITH MCC,865,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
VIRAL ILLNESS WITHOUT MCC,866,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DEPRESSIVE NEUROSES,881,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NEUROSES EXCEPT DEPRESSIVE,882,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PSYCHOSES,885,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MENTAL DISORDER DIAGNOSES,887,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HAND PROCEDURES FOR INJURIES,906,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
TRAUMATIC INJURY WITH MCC,913,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
TRAUMATIC INJURY WITHOUT MCC,914,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ALLERGIC REACTIONS WITH MCC,915,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
ALLERGIC REACTIONS WITHOUT MCC,916,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
COMPLICATIONS OF TREATMENT WITH MCC,919,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
COMPLICATIONS OF TREATMENT WITH CC,920,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NON-EXTENSIVE BURNS,935,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
REHABILITATION WITH CC/MCC,945,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
REHABILITATION WITHOUT CC/MCC,946,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SIGNS AND SYMPTOMS WITH MCC,947,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
SIGNS AND SYMPTOMS WITHOUT MCC,948,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
AFTERCARE WITH CC/MCC,949,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
AFTERCARE WITHOUT CC/MCC,950,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,998,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,
UNGROUPABLE,999,CDM,100,RC,,,Inpatient,,,,,,2846,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2345.31,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,3514,100,,,Per Diem,Pays based on per day rate,2846,100,,,Per Diem,Pays based on per day rate,2235,100,,,Case Rate,Pays based on per visit rate,2277,100,,,Per Diem,Pays based on per day rate,2235,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2277,100,,,Per Diem,Pays based on per day rate,2198,3514,